Healthcare Provider Details

I. General information

NPI: 1295191864
Provider Name (Legal Business Name): JAMES GIBSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

IV. Provider business mailing address

36 WOODVALE AVE
KINGS PARK NY
11754-1028
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-9033
  • Fax:
Mailing address:
  • Phone: 631-456-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number019387
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: