MEDICARE: NICOLE GIBBONS 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
1	363A00000X	Physician Assistant	PA9107929	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y0R3M	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730580242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GIBBONS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 917770
Second Line	:	SUITE B-1
City	:	ORLANDO
State	:	FL
Zip	:	32891-0001
Country	:	US
Telephone Number	:	813-821-8038
Fax Number	:

Provider Business Practice Location Address
First Line	:	5420 WEBB RD
Second Line	:	SUITE B-1
City	:	TAMPA
State	:	FL
Zip	:	33615-3250
Country	:	US
Telephone Number	:	813-886-0548
Fax Number	:	813-886-0890

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	12/07/2025

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