Provider Demographics
NPI:1295151405
Name:GIBSON, RICKY L (CRNA)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5880
Mailing Address - Country:US
Mailing Address - Phone:817-598-8150
Mailing Address - Fax:
Practice Address - Street 1:590 MEDICAL CENTER ROAD
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-8197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125380367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered