Provider Demographics
NPI:1760169130
Name:GIBSON, TAYLOR A (APRN)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-868-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:1417 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:KY
Practice Address - Zip Code:42629-0966
Practice Address - Country:US
Practice Address - Phone:270-343-2597
Practice Address - Fax:270-343-2598
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4010096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
15937325OtherCAQH