Basic Information
| Provider Information | |||||||||
| NPI: | 1265844245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LUCIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079890550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2014 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD21840 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.