Basic Information
| Provider Information | |||||||||
| NPI: | 1053733394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | MYKENZI | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 SAILING CLUB DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292297359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035465768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 RICHLAND MEDICAL PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034343800 | ||||||||
| FaxNumber: | 8037442759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2014 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2021 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2089PA | 05 | SC | MEDICAID |