Provider Demographics
NPI:1487681201
Name:GIBSON, MICHAEL J (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:100 MCDOUGAL DR
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-2822
Mailing Address - Country:US
Mailing Address - Phone:405-379-4202
Mailing Address - Fax:405-379-4340
Practice Address - Street 1:100 MCDOUGAL DR
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-2822
Practice Address - Country:US
Practice Address - Phone:405-379-4202
Practice Address - Fax:405-379-4340
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK199363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0784740001OtherDMERC REGION C
OK100848080AMedicaid
P00266954OtherPALMETTO GBA RAILROAD MC
0784740001OtherDMERC REGION C
OK100848080AMedicaid