Provider Demographics
NPI:1508585928
Name:GIBBS, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:GIBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8731 PARK PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5682
Mailing Address - Country:US
Mailing Address - Phone:318-524-7144
Mailing Address - Fax:318-797-5844
Practice Address - Street 1:1549 E 70TH ST STE 300
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5056
Practice Address - Country:US
Practice Address - Phone:318-300-3898
Practice Address - Fax:318-797-4241
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA333903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant