Provider Demographics
NPI:1336372515
Name:GIBSON, LAUREN BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:BETH
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-3200
Mailing Address - Fax:208-302-3255
Practice Address - Street 1:4424 E FLAMINGO AVET
Practice Address - Street 2:STE 110
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-302-3200
Practice Address - Fax:208-302-3255
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000671363AM0700X
DEC50000671207P00000X, 363AS0400X
IDPA-1934363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE164577Y0DMedicare PIN