Basic Information
Provider Information
NPI: 1003002858
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GIBSON
FirstName: AMY
MiddleName: R.
NamePrefix:  
NameSuffix:  
Credential: APN-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1314 PARK AVE
Address2:  
City: PLAINFIELD
State: NJ
PostalCode: 070603253
CountryCode: US
TelephoneNumber: 9082228970
FaxNumber: 9082228762
Practice Location
Address1: 1314 PARK AVE
Address2:  
City: PLAINFIELD
State: NJ
PostalCode: 070603253
CountryCode: US
TelephoneNumber: 9082228970
FaxNumber: 9082228762
Other Information
ProviderEnumerationDate: 09/14/2007
LastUpdateDate: 09/14/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X26NC08675800NJY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 

No ID Information.


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