Provider Demographics
NPI:1366024259
Name:GIBSON, CAMERON RICHARD
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:RICHARD
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 GREENBRIAR TOWNHOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-2449
Mailing Address - Country:US
Mailing Address - Phone:951-219-8572
Mailing Address - Fax:
Practice Address - Street 1:240 S HUMAHUACA ST
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-2199
Practice Address - Country:US
Practice Address - Phone:775-751-7406
Practice Address - Fax:775-751-7409
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator