Healthcare Provider Details

I. General information

NPI: 1639192792
Provider Name (Legal Business Name): SHEILA O'SHEA GIBBENS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PASEO DEPERLTA
SANTA FE NM
87501-2233
US

IV. Provider business mailing address

PO BOX 1485
PENA BLANCA NM
87041-1485
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-1575
  • Fax: 505-467-1577
Mailing address:
  • Phone: 505-467-1575
  • Fax: 505-467-1577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2002-0013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: