Provider Demographics
NPI:1245310135
Name:GIBSON, CARLA (APRN)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 S RESERVE ST # 401
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6451
Mailing Address - Country:US
Mailing Address - Phone:406-543-5444
Mailing Address - Fax:406-543-5447
Practice Address - Street 1:10795 ORAL ZUMWALT WAY
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-9791
Practice Address - Country:US
Practice Address - Phone:406-543-5444
Practice Address - Fax:406-543-5447
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT016250363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT373780OtherBLUE CROSS BLUE SHIELD
MT4302402Medicaid
MT000083657Medicare ID - Type Unspecified
S28681Medicare UPIN