Provider Demographics
NPI:1265689616
Name:GIBSON, TANYA MARIA (BSIS EDUCATION)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:BSIS EDUCATION
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:MARIA
Other - Last Name:ROWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSIS EDUCATION
Mailing Address - Street 1:3352 N FUTRALL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4057
Mailing Address - Country:US
Mailing Address - Phone:479-521-5868
Mailing Address - Fax:
Practice Address - Street 1:701 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2105
Practice Address - Country:US
Practice Address - Phone:870-772-2170
Practice Address - Fax:870-772-2138
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator