Provider Demographics
NPI:1356894596
Name:GIBSON, THIAGO (CRNP-FNP)
Entity type:Individual
Prefix:
First Name:THIAGO
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:CRNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 FIELDBROOK LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-4055
Mailing Address - Country:US
Mailing Address - Phone:301-367-4046
Mailing Address - Fax:844-772-9186
Practice Address - Street 1:2101 MEDICAL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4053
Practice Address - Country:US
Practice Address - Phone:301-802-6493
Practice Address - Fax:844-772-9186
Is Sole Proprietor?:No
Enumeration Date:2016-07-24
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR197629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily