Provider Demographics
NPI:1003002858
Name:GIBSON, AMY R (APN-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-3253
Mailing Address - Country:US
Mailing Address - Phone:908-222-8970
Mailing Address - Fax:908-222-8762
Practice Address - Street 1:1314 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-3253
Practice Address - Country:US
Practice Address - Phone:908-222-8970
Practice Address - Fax:908-222-8762
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC08675800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ35230Medicare UPIN