Provider Demographics
NPI:1255845517
Name:GIBSON, KRISTINA YVONNE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:YVONNE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:YVONNE
Other - Last Name:KEILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-24
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6978207PE0004X, 2080P0204X, 2086S0120X
AZ68792086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine