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General NPI Number Information
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NPI Number | 1093721714
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Entity Type | Individual
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Provider Name | JACQUELINE GAILLARD GIBSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 820 S BOYLAN AVE
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City | RALEIGH
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State | NC
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Zip | 27603-2246
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Country | US
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Telephone | 919-733-0740
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Fax |
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Provider Business Mailing Address
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Address Line | 216 WILD HOLLY LN
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-8654
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Country | US
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Telephone | 919-557-6040
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 103859
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License Number State | NC
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