Provider Demographics
NPI:1457683047
Name:GIBBA, MICHAEL E (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:GIBBA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 GRAND HL
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2612
Mailing Address - Country:US
Mailing Address - Phone:612-343-3265
Mailing Address - Fax:612-343-3267
Practice Address - Street 1:801 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1136
Practice Address - Country:US
Practice Address - Phone:612-343-3265
Practice Address - Fax:612-343-3267
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR127647-7171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator