Provider Demographics
NPI:1790974723
Name:GIBSON, MARY J (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
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 1:2117 HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2408
Mailing Address - Country:US
Mailing Address - Phone:757-825-4273
Mailing Address - Fax:757-825-4276
Practice Address - Street 1:2117 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2408
Practice Address - Country:US
Practice Address - Phone:757-825-4273
Practice Address - Fax:757-825-4276
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167301363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care