MEDICARE: GRACE GIBBONS PA-S

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1982563615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE GIBBONS PA-S

Provider Business Mailing Address
First Line	:	12286 BRIDGEWATER WAY
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-2775
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12286 BRIDGEWATER WAY
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-2775
Country	:	US
Telephone Number	:	513-335-4177
Fax Number	:

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

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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Directions to “ GRACE GIBBONS PA-S” Practice Location

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