Provider Demographics
NPI:1033891387
Name:GIBBS, BAILEY WYNN (PA-C)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:WYNN
Last Name:GIBBS
Suffix:
Gender:F
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 1:715 SE LANOLA ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-6559
Mailing Address - Country:US
Mailing Address - Phone:719-580-6610
Mailing Address - Fax:
Practice Address - Street 1:2282 NW TROOST ST STE 103
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6072
Practice Address - Country:US
Practice Address - Phone:541-672-4798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA222229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant