Provider Demographics
NPI:1265306351
Name:GIBSON, CORY EVAN (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:EVAN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 BAKER PLACE LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4025
Mailing Address - Country:US
Mailing Address - Phone:229-402-1115
Mailing Address - Fax:
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6426
Practice Address - Country:US
Practice Address - Phone:706-651-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPRN-CRNA292640367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered