Provider Demographics
NPI:1417288093
Name:GIBSON, EDWARD ROY
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:ROY
Last Name:GIBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 BEAVER BROOK DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4167
Mailing Address - Country:US
Mailing Address - Phone:706-650-2053
Mailing Address - Fax:
Practice Address - Street 1:2260 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4764
Practice Address - Country:US
Practice Address - Phone:803-278-2473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150012163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA413298719BMedicaid
SCGAN945Medicaid