Basic Information
| Provider Information | |||||||||
| NPI: | 1245515295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | GRAHAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 853 MARK DR | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443135842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163721914 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3635 VISTA | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2011 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2011032476 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.