Provider Demographics
NPI:1730562190
Name:GIBSON, SHANNON NICOLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:NICOLE
Last Name:GIBSON
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 1:21770 KINGSLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2513
Mailing Address - Country:US
Mailing Address - Phone:281-646-0740
Mailing Address - Fax:
Practice Address - Street 1:21770 KINGSLAND BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2513
Practice Address - Country:US
Practice Address - Phone:281-646-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX588159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant