Basic Information
| Provider Information | |||||||||
| NPI: | 1346301918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 728 MOLALLA AVE | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970452799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036569030 | ||||||||
| FaxNumber: | 5036569030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 BEAVERCREEK RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
| FaxNumber: | 5036558595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 11/23/2016 | ||||||||
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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 | 163W00000X | 080039641RN | OR | N | Nursing Service Providers | Registered Nurse | 363LC1500X | 200150136NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health |
No ID Information.