Basic Information
| Provider Information | |||||||||
| NPI: | 1609421023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | MONTANA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1004 LEAWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406013349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022237403 | ||||||||
| FaxNumber: | 5022235016 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 LEAWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406013349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022237403 | ||||||||
| FaxNumber: | 5022235016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2019 | ||||||||
| LastUpdateDate: | 08/02/2019 | ||||||||
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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 | 007739 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 007739 | 01 | KY | KENTUCKY BOARD OF PHYSICAL THERAPY | OTHER |