Provider Demographics
NPI:1205489804
Name:GIBSON, JONATHON ANDREW
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:ANDREW
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 1:2409 ACTON RD STE 153
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2939
Mailing Address - Country:US
Mailing Address - Phone:205-379-0174
Mailing Address - Fax:
Practice Address - Street 1:1715 N BUNNER ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2229
Practice Address - Country:US
Practice Address - Phone:205-379-0174
Practice Address - Fax:888-219-8102
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140866207X00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery