Provider Demographics
NPI:1346301918
Name:GIBSON, MARY ANN (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 MOLALLA AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2799
Mailing Address - Country:US
Mailing Address - Phone:503-656-9030
Mailing Address - Fax:503-656-9030
Practice Address - Street 1:1425 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4076
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:503-655-8595
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080039641RN163W00000X
OR200150136NP363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse