Provider Demographics
NPI:1104538537
Name:GIBSON, JULIA (PA)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1208
Mailing Address - Country:US
Mailing Address - Phone:858-554-1212
Mailing Address - Fax:858-795-1195
Practice Address - Street 1:380 STEVENS AVE STE 310
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2069
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:858-795-1195
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant