Provider Demographics
NPI:1205449261
Name:GIBSON, BRAD (APRN)
Entity type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10552 SUCCESS LN STE L
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3664
Mailing Address - Country:US
Mailing Address - Phone:937-280-5711
Mailing Address - Fax:
Practice Address - Street 1:10552 SUCCESS LN STE L
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3664
Practice Address - Country:US
Practice Address - Phone:937-280-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029637363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty