Basic Information
| Provider Information | |||||||||
| NPI: | 1427646496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | JOSHUA | ||||||||
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| Credential: | APRN FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12855 N 40 DR STE 375 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145676071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 326 FOUNTAINS PKWY | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622082041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182773109 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2021 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209.022464 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.