Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 202005263NP-PP | OR |
NPI | 1023633831 |
---|---|
Provider Name | Cory James Gibbens |
First Address | Florence, OR 97439-9470 |
Second Address | Florence, OR 97439-9470 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2020 |
Last Update Date | 22/06/2021 |