Healthcare Provider Details

I. General information

NPI: 1184863227
Provider Name (Legal Business Name): PATRICIA LYN GIBBONS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA LYN MARTIN CRNA

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 4008
PORTLAND OR
97208-4008
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax: 208-367-2742
Mailing address:
  • Phone: 503-372-2740
  • Fax: 503-372-2754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: