Provider Demographics
NPI:1326101700
Name:GIBSON, MELISSA SUE (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 BROADWAY EXT STE 201
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-6304
Mailing Address - Country:US
Mailing Address - Phone:405-419-5665
Mailing Address - Fax:405-419-5429
Practice Address - Street 1:9800 BROADWAY EXT STE 201
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6304
Practice Address - Country:US
Practice Address - Phone:405-419-5665
Practice Address - Fax:405-419-5429
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ29991Medicare UPIN