Provider Demographics
NPI:1144200411
Name:GIBSON, JAMES (FNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2724
Mailing Address - Country:US
Mailing Address - Phone:706-227-2027
Mailing Address - Fax:706-227-2433
Practice Address - Street 1:892 PRINCE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2724
Practice Address - Country:US
Practice Address - Phone:706-227-2027
Practice Address - Fax:706-227-2433
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000925922EMedicaid
GA000925922EMedicaid
GA50BBGSMMedicare PIN