=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033891387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BAILEY WYNN GIBBS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 09/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2282 NW TROOST ST STE 103
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-6072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-672-4798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 SE LANOLA ST
-----------------------------------------------------
City | WINSTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97496-6559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-580-6610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA222229
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------