Healthcare Provider Details

I. General information

NPI: 1619566833
Provider Name (Legal Business Name): ZACHARY GIBSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W STATE ROAD 164
SALEM UT
84653-5732
US

IV. Provider business mailing address

1055 N 500 W ATTN CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 385-265-6050
  • Fax: 801-798-7954
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10584263-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: