1265976765 NPI number — DILLON TYLER GIBSON PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265976765 NPI number — DILLON TYLER GIBSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
DILLON
Provider Middle Name:
TYLER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265976765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 W MORRIS BLVD STE 400D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37813-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-586-7509
Provider Business Mailing Address Fax Number:
423-317-8948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HEALTHSTAR PHYSICIANS
Provider Second Line Business Practice Location Address:
420 W. MORRIS BLVD SUITE 400D
Provider Business Practice Location Address City Name:
MORRISTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-586-7509
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  3169 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 3169 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Q027230 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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