Provider Demographics
NPI:1306463930
Name:GIBBS, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GIBBS
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 1:7512 GARDNER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7512 GARDNER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3414
Practice Address - Country:US
Practice Address - Phone:703-753-9860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily