Provider Demographics
NPI:1720701030
Name:GIBSON, MAYA (RD)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 PARMENTER ST APT 312
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1616
Mailing Address - Country:US
Mailing Address - Phone:608-234-0081
Mailing Address - Fax:
Practice Address - Street 1:1675 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0002
Practice Address - Country:US
Practice Address - Phone:608-234-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric