Provider Demographics
NPI:1174578835
Name:GIBSON, CRYSTAL D (PA C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 MEDICAL CENTER DR STE 1A
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9477
Mailing Address - Country:US
Mailing Address - Phone:606-439-5220
Mailing Address - Fax:606-439-5221
Practice Address - Street 1:101 TOWN AND COUNTRY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9524
Practice Address - Country:US
Practice Address - Phone:606-439-1300
Practice Address - Fax:606-439-1400
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KYPA807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004271Medicaid
KY0201688Medicare ID - Type Unspecified
KY95004271Medicaid