Provider Demographics
NPI:1922866359
Name:GIBSON, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 ELMONT RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-5126
Mailing Address - Country:US
Mailing Address - Phone:573-205-8376
Mailing Address - Fax:
Practice Address - Street 1:1191 ELMONT RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-5126
Practice Address - Country:US
Practice Address - Phone:573-205-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)