Provider Demographics
NPI:1053465559
Name:GIBBON, LAWRENCE KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:KAY
Last Name:GIBBON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:185 W 4TH AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7298
Mailing Address - Country:US
Mailing Address - Phone:208-773-1592
Mailing Address - Fax:208-773-9764
Practice Address - Street 1:185 W 4TH AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7298
Practice Address - Country:US
Practice Address - Phone:208-773-1592
Practice Address - Fax:208-773-9764
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID080002699OtherRAILROAD MDC
ID41939OtherBLUE CROSS
ID0007628Medicaid
ID000010006362OtherREGENCE BLUE SHIELD
ID41939OtherBLUE CROSS
ID0007628Medicaid
ID1115345Medicare PIN