Basic Information
| Provider Information | |||||||||
| NPI: | 1114319670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | ANDREW | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 W 21ST AVE | ||||||||
| Address2: | |||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851207403 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | 300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022776211 | ||||||||
| FaxNumber: | 8662425309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10489 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10489 | 01 | AZ | LICENSE | OTHER |