Basic Information
| Provider Information | |||||||||
| NPI: | 1700904406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470 | ||||||||
| Address2: | |||||||||
| City: | KOTZEBUE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997520470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074427148 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 212 CARLANNA LAKE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072288140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 01/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5493 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A51581 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 29061 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD3965 | 05 | AK | MEDICAID |