Basic Information
Provider Information | |||||||||
NPI: | 1821058520 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GIBSON | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OBLENDER | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 540 N DUKE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176022374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175446111 | ||||||||
FaxNumber: | 7175442625 | ||||||||
Practice Location | |||||||||
Address1: | 540 N DUKE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176022374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175446111 | ||||||||
FaxNumber: | 7175442625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2006 | ||||||||
LastUpdateDate: | 01/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA051182 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 118571 | 01 | PA | AETNA | OTHER | 50012708 | 01 | PA | BLUE CROSS | OTHER | 210103 | 01 | PA | HEALTHAMERICA/HEALTHASSUR | OTHER |