Provider Demographics
NPI:1346207586
Name:GIBBONS, RICHARD B (ARNP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 SW NEWLAND WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6966
Mailing Address - Country:US
Mailing Address - Phone:386-758-0003
Mailing Address - Fax:386-755-7940
Practice Address - Street 1:1859 SW NEWLAND WAY
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6966
Practice Address - Country:US
Practice Address - Phone:386-758-0003
Practice Address - Fax:386-755-7940
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1144982363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307264900Medicaid