Provider Demographics
NPI:1093721714
Name:GIBSON, JACQUELINE GAILLARD (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:GAILLARD
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 WILD HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-8654
Mailing Address - Country:US
Mailing Address - Phone:919-557-6040
Mailing Address - Fax:
Practice Address - Street 1:820 S BOYLAN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2246
Practice Address - Country:US
Practice Address - Phone:919-733-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103859363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical