Provider Demographics
NPI:1376774034
Name:GIBSON, MICHAEL L (FNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:HAYFORK
Mailing Address - State:CA
Mailing Address - Zip Code:96041-0220
Mailing Address - Country:US
Mailing Address - Phone:530-628-5517
Mailing Address - Fax:530-628-5524
Practice Address - Street 1:6961 HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:HAYFORK
Practice Address - State:CA
Practice Address - Zip Code:96041-6961
Practice Address - Country:US
Practice Address - Phone:530-628-5517
Practice Address - Fax:530-628-5524
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner