Provider Demographics
NPI:1659130888
Name:GIBSON, COLLEEN (APNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-2976
Practice Address - Street 1:700 S PARK ST STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-2976
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15152363L00000X
WI1515233363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659130888Medicaid