Provider Demographics
NPI:1760172464
Name:GIBSON, BENJAMIN (RN)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:RN
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 2361
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:43008-2361
Mailing Address - Country:US
Mailing Address - Phone:740-255-0804
Mailing Address - Fax:
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9718
Practice Address - Country:US
Practice Address - Phone:740-255-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH399354163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice