Provider Demographics
NPI:1164473294
Name:GIBSON, WAYNE ST M (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ST M
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 20TH AVE N STE 403
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5180
Mailing Address - Country:US
Mailing Address - Phone:615-284-7261
Mailing Address - Fax:615-284-7501
Practice Address - Street 1:301 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:731-644-8226
Practice Address - Fax:731-847-1121
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040911A207RC0000X
KY29083207RC0000X
TN60311207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200040820BMedicaid
KY64290836Medicaid
INP01407761 (KOHMG) RRMedicare PIN
IN228550011 (KOHMG)Medicare PIN
KYP01407759 (KOHMG) RRMedicare PIN
KYK083431Medicare PIN
IN200040820BMedicaid