Provider Demographics
NPI:1629053525
Name:GIBSON, LORETTA MINER (CRNA)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:MINER
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14145 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-2724
Mailing Address - Country:US
Mailing Address - Phone:909-268-5549
Mailing Address - Fax:909-363-7416
Practice Address - Street 1:14145 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-2724
Practice Address - Country:US
Practice Address - Phone:909-268-5549
Practice Address - Fax:909-363-7416
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA3135367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3686700Medicaid
CARN3686700Medicaid
ZZZ282182Medicare ID - Type Unspecified