Provider Demographics
NPI:1699528372
Name:GIBBS, DEANDRA RAYSHON
Entity type:Individual
Prefix:
First Name:DEANDRA
Middle Name:RAYSHON
Last Name:GIBBS
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 1:2124 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-6158
Mailing Address - Country:US
Mailing Address - Phone:786-904-5758
Mailing Address - Fax:
Practice Address - Street 1:2124 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6158
Practice Address - Country:US
Practice Address - Phone:786-904-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory