Provider Demographics
NPI:1184684227
Name:GIBB, KENNETH ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:GIBB
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 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:975 RYLAND ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1669
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-3900
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14284207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1577652Medicaid
NV1184684227Medicaid
MI010F362410OtherBCBSM
11276898OtherCAQH
MI010F362410OtherBCBSM
MI1577652Medicaid
MIB49441Medicare UPIN
NV1184684227Medicaid