Provider Demographics
NPI:1003218876
Name:GIBSON, WILLIAM G IV (FNP-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:GIBSON
Suffix:IV
Gender:M
Credentials:FNP-C
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 370
Mailing Address - Street 2:
Mailing Address - City:RUSH CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55069-0370
Mailing Address - Country:US
Mailing Address - Phone:320-358-0987
Mailing Address - Fax:320-358-3422
Practice Address - Street 1:460 S ELIOT AVE
Practice Address - Street 2:
Practice Address - City:RUSH CITY
Practice Address - State:MN
Practice Address - Zip Code:55069-6505
Practice Address - Country:US
Practice Address - Phone:320-358-0987
Practice Address - Fax:320-358-3422
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2512775163W00000X
OHCOA.17029-NP363LF0000X
MN10136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse