Provider Demographics
NPI:1194099143
Name:GIBSON, DIANNA R (CRNA)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-7398
Mailing Address - Country:US
Mailing Address - Phone:555-555-5555
Mailing Address - Fax:
Practice Address - Street 1:400 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7398
Practice Address - Country:US
Practice Address - Phone:555-555-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012007166367500000X
WVAPRN99562367500000X
MDR229632367500000X
TN16886367500000X
OR202010013CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I433982Medicare PIN