MEDICARE: LINDSAY R. GIBBONS NP

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
1	363L00000X	Nurse Practitioner	4704234804	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124184460	OTHER	MI	TRICARE NPI
2	5008771990	OTHER	MN	BLUE CROSS BLUE SHIELD PIN

General Provider Information

NPI Number	:	1124184460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDSAY R. GIBBONS NP

Provider Business Mailing Address
First Line	:	PO BOX 150036
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49515-0036
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3210 EAGLE RUN DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-7051
Country	:	US
Telephone Number	:	616-456-9553
Fax Number	:	616-454-5371

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	05/24/2024

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