Provider Demographics
NPI:1194353805
Name:GIBSON, RYAN WESLEY
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:WESLEY
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W SPOFFORD AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-4666
Mailing Address - Country:US
Mailing Address - Phone:208-691-3339
Mailing Address - Fax:
Practice Address - Street 1:550 W HONEYSUCKLE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6042
Practice Address - Country:US
Practice Address - Phone:208-209-4081
Practice Address - Fax:208-209-4057
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60900576183500000X
IDI63666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist