Provider Demographics
NPI:1700896685
Name:GIBSON, TRACY (CNM)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4835
Mailing Address - Country:US
Mailing Address - Phone:208-239-3412
Mailing Address - Fax:208-239-3441
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4835
Practice Address - Country:US
Practice Address - Phone:208-239-3412
Practice Address - Fax:208-239-3441
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM33367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805053800Medicaid
IDNPYT9OtherBLUE CROSS OF IDAHO
IDP00175232OtherRAILROAD MEDICARE
ID000010146389OtherREGENCE BLUE SHIELD OF ID
IDS73428Medicare UPIN
ID000010146389OtherREGENCE BLUE SHIELD OF ID