Provider Demographics
NPI:1366881021
Name:GIBBS, AMANDA MARGARET (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARGARET
Last Name:GIBBS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARGARET
Other - Last Name:FUSILIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2424 W INDIAN TRL STE B
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1588
Mailing Address - Country:US
Mailing Address - Phone:630-882-9303
Mailing Address - Fax:
Practice Address - Street 1:535 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017
Practice Address - Country:US
Practice Address - Phone:715-243-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004269363A00000X
MN12656363A00000X
WI4337-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant