Provider Demographics
NPI:1447686050
Name:GIBSON, SANDRA E (PA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:E
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:E
Other - Last Name:SEKUTERSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5496 E TAFT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3784
Mailing Address - Country:US
Mailing Address - Phone:315-552-6700
Mailing Address - Fax:315-552-6701
Practice Address - Street 1:5496 E TAFT RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3784
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:315-552-6701
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03804024Medicaid
NYJ400123608Medicare PIN