Provider Demographics
NPI:1083895999
Name:GIBBONS, MICHAEL JOSEPH (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SCENIC HILLS DR
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-3022
Mailing Address - Country:US
Mailing Address - Phone:631-775-9317
Mailing Address - Fax:
Practice Address - Street 1:12 SCENIC HILLS DR
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-3022
Practice Address - Country:US
Practice Address - Phone:631-775-9317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4501131163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health