Provider Demographics
NPI:1699714907
Name:GIBSON, MARY E (APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7804 W GOLF DR APT 2B
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-3067
Mailing Address - Country:US
Mailing Address - Phone:708-481-4200
Mailing Address - Fax:708-481-3302
Practice Address - Street 1:4749 LINCOLN MALL DR STE 204
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3806
Practice Address - Country:US
Practice Address - Phone:708-481-4200
Practice Address - Fax:708-481-3320
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000390363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01619268OtherBLUESHIELD NUMBER
IL01619268OtherBLUESHIELD NUMBER
ILK31323Medicare PIN
IL209094Medicare PIN
IL324853Medicare PIN
IL500040641Medicare PIN
IL212037Medicare PIN
ILK11436Medicare PIN
IL01619268OtherBLUESHIELD NUMBER
IL$$$$$$$$$001Medicaid