Provider Demographics
NPI:1457634008
Name:GIBSON, ROBERT NORTH (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NORTH
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20422 MOONCREST CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4748
Mailing Address - Country:US
Mailing Address - Phone:714-390-2072
Mailing Address - Fax:
Practice Address - Street 1:3801 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7901
Practice Address - Country:US
Practice Address - Phone:714-751-5555
Practice Address - Fax:714-751-9999
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5892363A00000X
CAPA21862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ967373Medicaid