Provider Demographics
NPI:1073544516
Name:GIBSON, ALYCIA D (PAC)
Entity Type:Individual
Prefix:MRS
First Name:ALYCIA
Middle Name:D
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 HIGHWAY 140 S
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-5121
Mailing Address - Country:US
Mailing Address - Phone:731-243-4826
Mailing Address - Fax:
Practice Address - Street 1:239 TYSON AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4544
Practice Address - Country:US
Practice Address - Phone:731-644-8208
Practice Address - Fax:731-644-8551
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001274363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44D2000904OtherCLIA
TN1515861Medicaid
3664320Medicare ID - Type Unspecified
TN1515861Medicaid