Provider Demographics
NPI:1427646496
Name:GIBSON, JOSHUA (APRN FNP-C)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR STE 375
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:
Practice Address - Street 1:326 FOUNTAINS PKWY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2041
Practice Address - Country:US
Practice Address - Phone:618-277-3109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner