Provider Demographics
NPI:1700801073
Name:CLARK GIBSON, ANNA KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:KATHERINE
Last Name:CLARK GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 219672
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64121-9672
Mailing Address - Country:US
Mailing Address - Phone:816-407-4200
Mailing Address - Fax:816-781-6973
Practice Address - Street 1:2521 GLENN HENDREN DR STE 108
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3388
Practice Address - Country:US
Practice Address - Phone:816-781-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011007284208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO35789048OtherBCBS
SC309393Medicaid
NC5909852OtherMEDICAID NC
MO35789048OtherBCBS
SC309393Medicaid
MOMA417063Medicare PIN
MOMA5096067Medicare PIN
NC5909852OtherMEDICAID NC
SCAA29187153Medicare PIN