Provider Demographics
NPI:1104814524
Name:GIBSON, SARA FAITH (MD)
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:FAITH
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:470 W CLEVELAND
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-0579
Mailing Address - Country:US
Mailing Address - Phone:928-333-2683
Mailing Address - Fax:928-333-5595
Practice Address - Street 1:1300 S YALE ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6328
Practice Address - Country:US
Practice Address - Phone:928-774-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ199502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF46834OtherUPIN
AZZ78372OtherMEDICARE LEGACY GROUP #
AZZ78374OtherMEDICARE PROVIDER NUMBER
AZAZ0609250OtherBCBS PIN