Provider Demographics
NPI:1710457940
Name:GIBBS, ANTHONY CLARK
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:CLARK
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WONDER WORLD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7558
Mailing Address - Country:US
Mailing Address - Phone:512-396-3911
Mailing Address - Fax:512-353-0807
Practice Address - Street 1:1320 WONDER WORLD DR STE 101
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7558
Practice Address - Country:US
Practice Address - Phone:512-396-3911
Practice Address - Fax:512-353-0807
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q00089709OtherRR MEDICARE
1P6578OtherMEDICARE
TXPENDINGMedicaid