Provider Demographics
NPI:1023263894
Name:GIBB, JUSTIN R (CRNA)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:R
Last Name:GIBB
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2263
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2263
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:1828 S MILLENIUM WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5036
Practice Address - Country:US
Practice Address - Phone:208-381-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA728367500000X
OR200860041CRNA367500000X
UT5718917-4405367500000X
MO2008030098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
2701125OtherREGENCE
P00725584OtherRAILROAD MEDICARE
ID1023263894Medicaid
OR500603268Medicaid