MEDICARE: DR. ERICA ELLIS GIBSON MD

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	207Q00000X	Family Medicine Physician	04-29201	KS
2	207Q00000X	Family Medicine Physician	2011027717	MO

General Provider Information

NPI Number	:	1932101631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERICA ELLIS GIBSON MD

Provider Business Mailing Address
First Line	:	8350 N CHURCH RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64158-1104
Country	:	US
Telephone Number	:	913-297-7472
Fax Number	:

Provider Business Practice Location Address
First Line	:	8350 N CHURCH RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64158-1104
Country	:	US
Telephone Number	:	913-297-7472
Fax Number	:

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	09/22/2022

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