Provider Demographics
NPI:1063960946
Name:GIBSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 MOON ST NE
Mailing Address - Street 2:APT 324
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1461
Mailing Address - Country:US
Mailing Address - Phone:850-228-2486
Mailing Address - Fax:
Practice Address - Street 1:6001 MOON ST NE
Practice Address - Street 2:APT 324
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1461
Practice Address - Country:US
Practice Address - Phone:850-228-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other