Provider Demographics
NPI:1619209194
Name:GILSON, MIRIAM ELIZABETH (MSTOM, LAC)
Entity Type:Individual
Prefix:MISS
First Name:MIRIAM
Middle Name:ELIZABETH
Last Name:GILSON
Suffix:
Gender:F
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 ORANGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118
Mailing Address - Country:US
Mailing Address - Phone:619-634-9550
Mailing Address - Fax:
Practice Address - Street 1:543 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118
Practice Address - Country:US
Practice Address - Phone:619-634-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13094171100000X
CA113798171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist