Basic Information
| Provider Information | |||||||||
| NPI: | 1083000129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | NADINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | DPT | ||||||||
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| OtherLastName: | ERNO | ||||||||
| OtherFirstName: | NADINE | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1257 W WARNER RD | ||||||||
| Address2: | STE A-2 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852242713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808212286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6824 E BROWN RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852073705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809245514 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2015 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 10499 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.