Basic Information
| Provider Information | |||||||||
| NPI: | 1952574048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIST | ||||||||
| FirstName: | GAVIN | ||||||||
| MiddleName: | GILES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, ACNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8060 WOLF RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012711000 | ||||||||
| FaxNumber: | 9012714187 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BAPTIST MEMORIAL CIR STE 201 | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386554476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012711000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R862250 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 05752310 | 05 | MS | MEDICAID |