Basic Information
| Provider Information | |||||||||
| NPI: | 1457548430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | KERI | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1525 W 2100 S | ||||||||
| Address2: | REDWOOD HEALTH CENTER | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841191401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012139900 | ||||||||
| FaxNumber: | 8012139185 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 W 2100 S | ||||||||
| Address2: | REDWOOD HEALTH CENTER | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841191401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012139900 | ||||||||
| FaxNumber: | 8012139185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 6359011-1205 | UT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.