Provider Demographics
NPI:1356796353
Name:GIBSON, AMANDA REAVIS (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:REAVIS
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEAN
Other - Last Name:REAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25A JUNE ST STE 111
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2642
Mailing Address - Country:US
Mailing Address - Phone:207-490-7998
Mailing Address - Fax:
Practice Address - Street 1:25A JUNE ST STE 111
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2642
Practice Address - Country:US
Practice Address - Phone:207-490-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD27893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine