Provider Demographics
NPI:1982140844
Name:GIBSON, SIMON JACK (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:JACK
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N CEDAR BLUFF RD
Mailing Address - Street 2:STE 300
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-3632
Mailing Address - Country:US
Mailing Address - Phone:865-342-8900
Mailing Address - Fax:865-691-0843
Practice Address - Street 1:8915 POTOMAC DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2008
Practice Address - Country:US
Practice Address - Phone:601-826-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-CRNA000891367500000X
MS877434163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse