Provider Demographics
NPI:1932692829
Name:GIBSON, MATTHEW A (RNFA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:M
Credentials:RNFA
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 50924
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85076-0924
Mailing Address - Country:US
Mailing Address - Phone:480-545-2610
Mailing Address - Fax:480-545-2673
Practice Address - Street 1:15060 S 39TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6612
Practice Address - Country:US
Practice Address - Phone:480-332-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN195359163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant