Provider Demographics
NPI:1205429453
Name:GIBSON, MONROE
Entity type:Individual
Prefix:
First Name:MONROE
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 1:157 MUNCY DR
Mailing Address - Street 2:
Mailing Address - City:DELBARTON
Mailing Address - State:WV
Mailing Address - Zip Code:25670-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:157 MUNCY DR
Practice Address - Street 2:
Practice Address - City:DELBARTON
Practice Address - State:WV
Practice Address - Zip Code:25670-9733
Practice Address - Country:US
Practice Address - Phone:304-426-5890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker