Provider Demographics
NPI:1689236077
Name:GIBSON, COURTNEY SHAE (NP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:SHAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:364 SE 8TH AVE STE 108A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4253
Practice Address - Country:US
Practice Address - Phone:503-640-3687
Practice Address - Fax:503-640-3688
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141935363L00000X
NH092344-23363L00000X
OR10024300-APRN363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX401436702Medicaid
TX401436703Medicaid