Provider Demographics
NPI:1750483129
Name:GIBSON, SHONA (NP)
Entity Type:Individual
Prefix:
First Name:SHONA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 GORE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1119
Mailing Address - Country:US
Mailing Address - Phone:617-575-5850
Mailing Address - Fax:
Practice Address - Street 1:545A CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-522-5464
Practice Address - Fax:617-524-2966
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208489363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0349232Medicaid
MANP2766Medicare PIN
MAP19959Medicare UPIN