Provider Demographics
NPI:1144687609
Name:GIBSON, DESEK CORAY (PA-C)
Entity type:Individual
Prefix:
First Name:DESEK
Middle Name:CORAY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DESEK
Other - Middle Name:CORAY
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 FIRSTVILLAGE DRIVE
Mailing Address - Street 2:PO BOX 2000
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-295-6831
Mailing Address - Fax:910-295-0244
Practice Address - Street 1:5 FIRSTVILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-295-6831
Practice Address - Fax:910-215-2539
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant