Provider Demographics
NPI:1558044156
Name:GIBSON, ZACKARY ETHAN
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:ETHAN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-3554
Mailing Address - Country:US
Mailing Address - Phone:937-479-6402
Mailing Address - Fax:
Practice Address - Street 1:209 S MULBERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3554
Practice Address - Country:US
Practice Address - Phone:937-479-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUC474522372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion