Healthcare Provider Details

I. General information

NPI: 1427337765
Provider Name (Legal Business Name): BRIAN CLAYTON GIBSON CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-268-5800
  • Fax: 601-261-3530
Mailing address:
  • Phone: 601-579-5463
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR872628
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR872628
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: