Provider Demographics
NPI:1962806208
Name:GIBSON, KYLE M (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:8770 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1918
Practice Address - Country:US
Practice Address - Phone:740-574-9090
Practice Address - Fax:740-356-4180
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA363A00000X
OH50.005555RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant