Provider Demographics
NPI:1649301052
Name:GIBBS, MARY ANN (DC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GIBBS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:45 N HOLLADAY DR
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138
Mailing Address - Country:US
Mailing Address - Phone:503-738-7343
Mailing Address - Fax:503-738-9946
Practice Address - Street 1:45 N HOLLADAY DR
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138
Practice Address - Country:US
Practice Address - Phone:503-738-7343
Practice Address - Fax:503-738-9946
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272517111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR076711Medicaid
OR862925002OtherREGENCE BLUE CROSS
ORR133843Medicare PIN