Provider Demographics
NPI:1053733394
Name:GIBBS, MYKENZI (PA-C)
Entity type:Individual
Prefix:
First Name:MYKENZI
Middle Name:
Last Name:GIBBS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SAILING CLUB DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7359
Mailing Address - Country:US
Mailing Address - Phone:803-546-5768
Mailing Address - Fax:
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8006
Practice Address - Country:US
Practice Address - Phone:803-434-3800
Practice Address - Fax:803-744-2759
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8248-23363A00000X
SC2021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053733394Medicaid
SC2089PAMedicaid