Provider Demographics
NPI:1144916297
Name:GIBSON, MARY TERESA (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14175 W INDIAN SCHOOL RD STE B4
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8494
Mailing Address - Country:US
Mailing Address - Phone:623-853-3832
Mailing Address - Fax:
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2635
Practice Address - Country:US
Practice Address - Phone:623-853-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2904482086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery