Provider Demographics
NPI:1245686161
Name:GIBSON, JONATHAN CURTIS (AGNP-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CURTIS
Last Name:GIBSON
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:
Practice Address - Street 1:330 E BELTLINE AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1267
Practice Address - Country:US
Practice Address - Phone:616-752-6235
Practice Address - Fax:616-752-6324
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704232359363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245686161Medicaid