Provider Demographics
NPI:1568594208
Name:GEBHART, MARTY B (CFNP)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:B
Last Name:GEBHART
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 GREENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4043
Mailing Address - Country:US
Mailing Address - Phone:601-605-1550
Mailing Address - Fax:
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:601-326-3537
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR845505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily