Provider Demographics
NPI:1881628311
Name:GIBSON, SAMUEL A (PA-C)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11277 VERNON PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3717
Mailing Address - Country:US
Mailing Address - Phone:814-724-1252
Mailing Address - Fax:
Practice Address - Street 1:11277 VERNON PLACE
Practice Address - Street 2:SUITE 200
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3717
Practice Address - Country:US
Practice Address - Phone:814-724-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000263L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA752783KUWMedicare PIN
PAS36662Medicare UPIN