Provider Demographics
NPI:1619566833
Name:GIBSON, ZACHARY (PA)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:
Practice Address - Street 1:264 W 100 S
Practice Address - Street 2:
Practice Address - City:SANTAQUIN
Practice Address - State:UT
Practice Address - Zip Code:84655-8012
Practice Address - Country:US
Practice Address - Phone:385-203-1250
Practice Address - Fax:801-812-5034
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10584263-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant