Provider Demographics
NPI:1821329459
Name:GIBSON, KAREN FAY (MLS (MT,CLS))
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:FAY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MLS (MT,CLS)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11574 HIGHWAY 26
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-9249
Mailing Address - Country:US
Mailing Address - Phone:307-857-6157
Mailing Address - Fax:
Practice Address - Street 1:29 BLACKCOAL DR.
Practice Address - Street 2:LABORATORY
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183543291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory