Provider Demographics
NPI:1861900805
Name:GIBSON, CURTIS WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:WAYNE
Last Name:GIBSON
Suffix:
Gender:M
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-743-6135
Mailing Address - Fax:423-743-0035
Practice Address - Street 1:1826 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650
Practice Address - Country:US
Practice Address - Phone:423-743-6135
Practice Address - Fax:423-743-0035
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant