Healthcare Provider Details

I. General information

NPI: 1306463930
Provider Name (Legal Business Name): MARK GIBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7512 GARDNER PARK DR
GAINESVILLE VA
20155-3414
US

IV. Provider business mailing address

7512 GARDNER PARK DR
GAINESVILLE VA
20155-3414
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-9860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179511
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: