Provider Demographics
NPI:1578061313
Name:GIBBONS, MARY ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:GIBBONS
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ROSE
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:4 ALLEGHENY CTR FL 7
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-5227
Mailing Address - Country:US
Mailing Address - Phone:412-330-2510
Mailing Address - Fax:412-330-5844
Practice Address - Street 1:490 E NORTH AVE STE 307
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4740
Practice Address - Country:US
Practice Address - Phone:412-359-5822
Practice Address - Fax:412-359-6620
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059698363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical