Provider Demographics
NPI:1902054695
Name:GIBSON, MIRAL K (NP-C)
Entity Type:Individual
Prefix:
First Name:MIRAL
Middle Name:K
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 CINEMA CIR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-0000
Mailing Address - Country:US
Mailing Address - Phone:304-470-0670
Mailing Address - Fax:
Practice Address - Street 1:402 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-1678
Practice Address - Country:US
Practice Address - Phone:304-269-3929
Practice Address - Fax:304-269-3911
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013138Medicaid
WVWV2226AMedicare PIN
OH000000699799OtherANTHEM
OH000000585746OtherANTHEM
OHNP28001Medicare PIN