Healthcare Provider Details

I. General information

NPI: 1043707763
Provider Name (Legal Business Name): LAKESHIA C GIBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 W BONNEVILLE AVE
LAS VEGAS NV
89106-0100
US

IV. Provider business mailing address

888 W BONNEVILLE AVE
LAS VEGAS NV
89106-0100
US

V. Phone/Fax

Practice location:
  • Phone: 702-483-6000
  • Fax: 702-483-6039
Mailing address:
  • Phone: 702-483-6000
  • Fax: 702-483-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number295334
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number295334
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25971
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number25971
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: