Healthcare Provider Details

I. General information

NPI: 1083176861
Provider Name (Legal Business Name): BRENNA A GIBBONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 BELL WEST BLVD
BELEVILLE WI
53508
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-3384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7766-851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number74034-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74034-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: