Provider Demographics
NPI:1184693574
Name:GIBBONS, MICHAEL T (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:CRNA
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 868
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0868
Mailing Address - Country:US
Mailing Address - Phone:772-286-0338
Mailing Address - Fax:772-287-1139
Practice Address - Street 1:421 SE OSCEOLA ST
Practice Address - Street 2:STE 3
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2505
Practice Address - Country:US
Practice Address - Phone:772-286-0338
Practice Address - Fax:772-287-1139
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN146302367500000X
FLARNP2948472367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN146302OtherNURSING LICENSE #
FLAQ780ZOtherFLORIDA MEDICARE
FLG4647OtherBCBS OF FLORIDA
FL0004722-00Medicaid