Provider Demographics
NPI:1487178299
Name:GIBSON, HEATH MARTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATH
Middle Name:MARTIN
Last Name:GIBSON
Suffix:
Gender:M
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 1:1138 LEXINGTON RD STE 140
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9672
Mailing Address - Country:US
Mailing Address - Phone:502-570-3721
Mailing Address - Fax:
Practice Address - Street 1:1138 LEXINGTON RD STE 140
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9672
Practice Address - Country:US
Practice Address - Phone:502-570-3721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant