Provider Demographics
NPI:1043758139
Name:GIBSON, MARIN
Entity Type:Individual
Prefix:
First Name:MARIN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13247
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95813-3247
Mailing Address - Country:US
Mailing Address - Phone:510-672-2083
Mailing Address - Fax:
Practice Address - Street 1:3100 COHASSET RD
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-0962
Practice Address - Country:US
Practice Address - Phone:530-342-8367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2023-12-17
Deactivation Date:2023-08-30
Deactivation Code:
Reactivation Date:2023-09-06
Provider Licenses
StateLicense IDTaxonomies
CA95026958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily