Provider Demographics
NPI:1639251630
Name:GIBSON, RANDALL P (LAC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:P
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3244
Mailing Address - Country:US
Mailing Address - Phone:415-209-9600
Mailing Address - Fax:415-893-1094
Practice Address - Street 1:920 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3244
Practice Address - Country:US
Practice Address - Phone:415-209-9600
Practice Address - Fax:415-893-1094
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5171171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist