Basic Information
| Provider Information | |||||||||
| NPI: | 1962427633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 34929 | ||||||||
| Address2: | P.O. BOX 39000 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941390001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259522828 | ||||||||
| FaxNumber: | 9259522850 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 BALFOUR RD | ||||||||
| Address2: | #120 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945134945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253088112 | ||||||||
| FaxNumber: | 9253088710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2003-0488 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C53949 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NM2003-0488 | 01 | NM | STATE LISCENSE NUMBER | OTHER | 55901085 | 05 | NM | MEDICAID | C53949 | 01 | CA | STATE LICENSE NUMBER | OTHER |