Provider Demographics
NPI:1659612760
Name:GIBSON, EMILY HENLEY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:HENLEY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:BETH
Other - Last Name:HENLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 HILLSDALE CIR
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 HILLSDALE CIR
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9754
Practice Address - Country:US
Practice Address - Phone:606-207-3295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01713363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9156433OtherGROUP MEDICARE