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NPI Code Detail

MEDICARE: ELLIE JO GIBBENS PA-C

MEDICARE: ELLIE JO GIBBENS PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician Assistant
2363A00000XPhysician Assistant63071CA
3363A00000XPhysician Assistant5461SC

General Provider Information

NPI Number : 1902580426
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLIE JO GIBBENS PA-C
Provider Business Mailing Address
First Line : 300 E MCBEE AVE FL 4
Second Line :
City : GREENVILLE
State : SC
Zip : 29601-2842
Country : US
Telephone Number : 803-434-6412
Fax Number :
Provider Business Practice Location Address
First Line : 975 W FARIS RD
Second Line :
City : GREENVILLE
State : SC
Zip : 29605-4241
Country : US
Telephone Number : 864-729-8330
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2023
Last Update Date : 02/09/2026

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Directions to “ ELLIE JO GIBBENS PA-C” Practice Location

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