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NPI Code Detail

MEDICARE: MRS. JACQUELINE GAILLARD GIBSON PA-C

MEDICARE: MRS. JACQUELINE GAILLARD GIBSON PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician Assistant103859NC

General Provider Information

NPI Number : 1093721714
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JACQUELINE GAILLARD GIBSON PA-C
Provider Business Mailing Address
First Line : 216 WILD HOLLY LN
Second Line :
City : HOLLY SPRINGS
State : NC
Zip : 27540-8654
Country : US
Telephone Number : 919-557-6040
Fax Number :
Provider Business Practice Location Address
First Line : 820 S BOYLAN AVE
Second Line :
City : RALEIGH
State : NC
Zip : 27603-2246
Country : US
Telephone Number : 919-733-0740
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/01/2006
Last Update Date : 07/08/2007

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