Healthcare Provider Details

I. General information

NPI: 1366446270
Provider Name (Legal Business Name): LISA MICHELLE GIBBONS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14508 NE 20TH AVE STE 300
VANCOUVER WA
98686-6418
US

IV. Provider business mailing address

14508 NE 20TH AVE STE 300
VANCOUVER WA
98686-6418
US

V. Phone/Fax

Practice location:
  • Phone: 360-433-0022
  • Fax: 360-433-6159
Mailing address:
  • Phone: 360-433-0022
  • Fax: 360-433-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOP00001992
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: