Provider Demographics
NPI:1902083611
Name:GIBSON, BRYAN GENE DEWHITT (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:GENE DEWHITT
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 TUCSON DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1744
Mailing Address - Country:US
Mailing Address - Phone:859-948-1649
Mailing Address - Fax:
Practice Address - Street 1:2300 TUCSON DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1744
Practice Address - Country:US
Practice Address - Phone:859-948-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant