Healthcare Provider Details

I. General information

NPI: 1063392272
Provider Name (Legal Business Name): KATHLEEN GIBSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 ORANGE PL
MAITLAND FL
32751-6531
US

IV. Provider business mailing address

146 ORANGE PL
MAITLAND FL
32751-6531
US

V. Phone/Fax

Practice location:
  • Phone: 407-389-2020
  • Fax:
Mailing address:
  • Phone: 407-389-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA9120235
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: