Basic Information
| Provider Information | |||||||||
| NPI: | 1205216579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC10 5600 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | DEPARTMENT OF ORTHOPAEDICS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724107 | ||||||||
| FaxNumber: | 5052728098 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE G1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623772663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | TRN21705 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207X00000X | 28979 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.