Healthcare Provider Details

I. General information

NPI: 1164340568
Provider Name (Legal Business Name): GRACE IRENE GIBSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 KENSINGTON AVE
BUFFALO NY
14215-1433
US

IV. Provider business mailing address

201 PORTSIDE
BUFFALO NY
14202-4357
US

V. Phone/Fax

Practice location:
  • Phone: 716-835-3097
  • Fax: 716-837-4654
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: