Provider Demographics
NPI:1962426742
Name:GIBSON, TODD EDWARD (MS,PA-C)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:EDWARD
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MS,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15150 PINEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-9147
Mailing Address - Country:US
Mailing Address - Phone:740-763-4581
Mailing Address - Fax:
Practice Address - Street 1:332 CONGRESS PARK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4133
Practice Address - Country:US
Practice Address - Phone:740-623-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002304363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP92975Medicare UPIN
OHGIPA25951Medicare ID - Type UnspecifiedOH M/C PROVIDER NUMBER