Provider Demographics
NPI:1801859012
Name:GIBSON, MARION P (PA)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:P
Last Name:GIBSON
Suffix:
Gender:M
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:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-0908
Mailing Address - Country:US
Mailing Address - Phone:918-426-0240
Mailing Address - Fax:918-423-4051
Practice Address - Street 1:1401 E VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4245
Practice Address - Country:US
Practice Address - Phone:918-426-0240
Practice Address - Fax:918-423-4051
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS45789Medicare UPIN
OKP00325992Medicare PIN