Provider Demographics
NPI:1841203478
Name:GIPSON, ERIC P (PHYS ASSIST CERT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:P
Last Name:GIPSON
Suffix:
Gender:M
Credentials:PHYS ASSIST CERT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3015 N BALLAS RD
Mailing Address - Street 2:DEPARTMENT OF CRITICAL CARE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2329
Mailing Address - Country:US
Mailing Address - Phone:314-996-7033
Mailing Address - Fax:314-996-5909
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:DEPARTMENT OF CRITICAL CARE
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-7033
Practice Address - Fax:314-996-5909
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO113938363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970008824Medicare PIN
000097239Medicare PIN
S78186Medicare UPIN