Provider Demographics
NPI:1962933135
Name:GIBSON, MICHAEL A II
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GIBSON
Suffix:II
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 1:5018 VALLEY EAST BLVD APT F
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521
Mailing Address - Country:US
Mailing Address - Phone:310-654-3910
Mailing Address - Fax:
Practice Address - Street 1:3300 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3463
Practice Address - Country:US
Practice Address - Phone:707-444-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator