Provider Demographics
NPI:1467461467
Name:GIBSON, DOLINDA H M (PA)
Entity Type:Individual
Prefix:
First Name:DOLINDA
Middle Name:H M
Last Name:GIBSON
Suffix:
Gender:F
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:DEPT 1188
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1188
Mailing Address - Country:US
Mailing Address - Phone:303-486-5504
Mailing Address - Fax:303-486-5501
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3597
Practice Address - Country:US
Practice Address - Phone:719-560-5855
Practice Address - Fax:719-560-4780
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO75283379Medicaid
P93706Medicare UPIN