Provider Demographics
NPI:1487090528
Name:GIBBY, WENDELL ANDREW (MD)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:ANDREW
Last Name:GIBBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4745
Mailing Address - Country:US
Mailing Address - Phone:801-229-2002
Mailing Address - Fax:
Practice Address - Street 1:3152 N UNIVERSITY AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4745
Practice Address - Country:US
Practice Address - Phone:801-229-2002
Practice Address - Fax:202-877-3288
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9875187-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program