Provider Demographics
NPI:1407535685
Name:GIBSON, ELAYNA BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:ELAYNA
Middle Name:BROOKE
Last Name:GIBSON
Suffix:
Gender:F
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:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9337
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:411 E CHESTNUT ST # 5A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-7450
Practice Address - Fax:502-588-7728
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC154363A00000X
IN10004124A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant