Provider Demographics
NPI:1407008519
Name:GIBSON, TRISTA L (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:TRISTA
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 MALL RD
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-6216
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-1518
Practice Address - Street 1:302 W MAIN ST.
Practice Address - Street 2:
Practice Address - City:SOPHIA
Practice Address - State:WV
Practice Address - Zip Code:25921
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV445363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical