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General NPI Number Information
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NPI Number | 1962426742
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Entity Type | Individual
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Provider Name | TODD EDWARD GIBSON MS,PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 332 CONGRESS PARK DR
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City | DAYTON
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State | OH
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Zip | 45459-4133
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Country | US
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Telephone | 740-623-4124
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Fax |
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Provider Business Mailing Address
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Address Line | 15150 PINEWOOD TRL
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City | NEWARK
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State | OH
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Zip | 43055-9147
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Country | US
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Telephone | 740-763-4581
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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 | 50-002304
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License Number State | OH
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