Provider Demographics
NPI:1164434163
Name:GIBSON, ANGELA GOODWIN (APMH-NP BC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:GOODWIN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APMH-NP BC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:GOODWIN
Other - Last Name:MORRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APMH-NP
Mailing Address - Street 1:2250 5TH STREET NORTH
Mailing Address - Street 2:BAPTIST MEMORIAL HOSPITAL GOLDEN TRIANGLE
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39701
Mailing Address - Country:US
Mailing Address - Phone:662-244-1000
Mailing Address - Fax:
Practice Address - Street 1:1500 E., WOODROW WILSON DR
Practice Address - Street 2:JACKSON VA MEDICAL CENTER
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR623334363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03108385Medicaid
MS500001219Medicare PIN
MSP82302Medicare UPIN