Provider Demographics
NPI:1518136126
Name:GIBSON, TIMOTHY J (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4012
Mailing Address - Country:US
Mailing Address - Phone:918-744-3664
Mailing Address - Fax:
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-2188
Practice Address - Fax:727-828-0723
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9320410367500000X
MO2003005268367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003865300Medicaid
FLG00SEOtherBCBS OF FL
FLG00SEOtherBCBS OF FL