Provider Demographics
NPI:1336734623
Name:GIBSON, DEVIN MASTAFA
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:MASTAFA
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 1:607 SAVANNAH ST SE APT 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-3809
Mailing Address - Country:US
Mailing Address - Phone:240-877-5388
Mailing Address - Fax:
Practice Address - Street 1:607 SAVANNAH ST SE APT 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3809
Practice Address - Country:US
Practice Address - Phone:240-877-5388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant