Provider Demographics
NPI:1710535562
Name:GIBERSON, GRACEY ANNA (PA)
Entity Type:Individual
Prefix:
First Name:GRACEY
Middle Name:ANNA
Last Name:GIBERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 S QUAIL HILL PL
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-4814
Mailing Address - Country:US
Mailing Address - Phone:360-957-5696
Mailing Address - Fax:
Practice Address - Street 1:3303 SW BOND AVE STE 7
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty