Provider Demographics
NPI:1457741407
Name:GIBSON, NICHOLAS R (PA-C, NREMT-P)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA-C, NREMT-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11700 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4656
Practice Address - Country:US
Practice Address - Phone:317-880-3900
Practice Address - Fax:317-880-0545
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10003409A363A00000X
GA7466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant