Provider Demographics
NPI:1861406597
Name:GIBSON, PATRICK R (PA-C, MHP)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA-C, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:ENFIELD MEDICAL ASSOCIATES
Practice Address - Street 2:701 ENFIELD STREET
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-741-6058
Practice Address - Fax:413-733-5860
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA510363A00000X
MAPA510363A00000X
CT5858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110165973AMedicaid
MAAP1017Medicare ID - Type Unspecified