Provider Demographics
NPI:1700868213
Name:GIBSON, TERESA R (WHNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3716 MELROSE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-2716
Mailing Address - Country:US
Mailing Address - Phone:540-362-0360
Mailing Address - Fax:540-366-2049
Practice Address - Street 1:3716 MELROSE AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-2716
Practice Address - Country:US
Practice Address - Phone:540-362-0360
Practice Address - Fax:540-366-2049
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007793103Medicaid
VA00048W70Medicare ID - Type Unspecified
VA007793103Medicaid
VA017135C19Medicare PIN