Basic Information
| Provider Information | |||||||||
| NPI: | 1447847769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | KAYLEY | ||||||||
| MiddleName: | JASMINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KILCOYNE | ||||||||
| OtherFirstName: | KAYLEY | ||||||||
| OtherMiddleName: | JASMINE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29 STEBBINS ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016071867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082080215 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 245 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020193007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7742954355 | ||||||||
| FaxNumber: | 7742954880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2020 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.