Provider Demographics
NPI:1700618378
Name:GIBSON, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 IRVING PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-1622
Mailing Address - Country:US
Mailing Address - Phone:440-310-4676
Mailing Address - Fax:
Practice Address - Street 1:532 IRVING PARK BLVD
Practice Address - Street 2:
Practice Address - City:SHEFFIELD LAKE
Practice Address - State:OH
Practice Address - Zip Code:44054-1622
Practice Address - Country:US
Practice Address - Phone:440-310-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker