Healthcare Provider Details

I. General information

NPI: 1972180065
Provider Name (Legal Business Name): CODY MEBANE GIBBONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SENECA ST
SEATTLE WA
98101-2742
US

IV. Provider business mailing address

1219 CASTLEROCK AVE
WENATCHEE WA
98801-2528
US

V. Phone/Fax

Practice location:
  • Phone: 206-583-6079
  • Fax:
Mailing address:
  • Phone: 509-679-2340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: