Provider Demographics
NPI:1649897372
Name:GIBSON, KYUNGRAN (PA-C)
Entity type:Individual
Prefix:
First Name:KYUNGRAN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21 CLARK WAY
Mailing Address - Street 2:
Mailing Address - City:SOMERSWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03878-4401
Mailing Address - Country:US
Mailing Address - Phone:603-692-2228
Mailing Address - Fax:603-692-4748
Practice Address - Street 1:330 BORTHWICK AVE STE 311
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7112
Practice Address - Country:US
Practice Address - Phone:603-692-2228
Practice Address - Fax:603-692-4748
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant