Provider Demographics
NPI:1770785339
Name:GIBSON, MISTY MICHELLE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MICHELLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 DIXON CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4302
Mailing Address - Country:US
Mailing Address - Phone:229-378-0295
Mailing Address - Fax:
Practice Address - Street 1:3340 PLAYERS CLUB PKWY
Practice Address - Street 2:SUITE 350
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8933
Practice Address - Country:US
Practice Address - Phone:901-844-1590
Practice Address - Fax:901-844-1592
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150024367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA431180317BMedicaid
SCGAN827Medicaid