Healthcare Provider Details

I. General information

NPI: 1346563145
Provider Name (Legal Business Name): CARLA DIANE GIBBS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLA DIANE COUCH PA-C

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 HOSPITAL DR
VICTORIA TX
77901-5748
US

IV. Provider business mailing address

2701 HOSPITAL DR
VICTORIA TX
77901-5748
US

V. Phone/Fax

Practice location:
  • Phone: 361-573-9181
  • Fax: 361-572-5126
Mailing address:
  • Phone: 361-573-9181
  • Fax: 361-572-5126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06556
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: