Provider Demographics
NPI:1306988514
Name:GIBSON, PAUL (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 N MULDOON RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-6109
Mailing Address - Country:US
Mailing Address - Phone:888-227-3312
Mailing Address - Fax:
Practice Address - Street 1:1118 N MULDOON RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004583363AM0700X
AK1069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPA1069OtherAK LICENSE
WA1060779OtherNCCPA
WAPA10004583OtherWA PA CERT
WAPA10004583OtherWA PA CERT
WAQ15127Medicare UPIN