Basic Information
| Provider Information | |||||||||
| NPI: | 1770713901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUBENDORFER | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | E. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 509 | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070390509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003450064 | ||||||||
| FaxNumber: | 9732511109 | ||||||||
| Practice Location | |||||||||
| Address1: | 176 PALISADE AVE | ||||||||
| Address2: | CHRIST HOSPITAL | ||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073061121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017958200 | ||||||||
| FaxNumber: | 9732511109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2009 | ||||||||
| LastUpdateDate: | 06/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00222400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.