Healthcare Provider Details

I. General information

NPI: 1679408587
Provider Name (Legal Business Name): RYAN GIBSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 AMHERST LN
HICKSVILLE NY
11801-3303
US

IV. Provider business mailing address

57 AMHERST LN
HICKSVILLE NY
11801-3303
US

V. Phone/Fax

Practice location:
  • Phone: 347-383-0769
  • Fax:
Mailing address:
  • Phone: 347-383-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number788590
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number788590
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: