Provider Demographics
NPI:1063632685
Name:GIBSON, TAMI LARAE X (LMT)
Entity Type:Individual
Prefix:MS
First Name:TAMI
Middle Name:LARAE
Last Name:GIBSON
Suffix:X
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W NACHES AVE
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-1323
Mailing Address - Country:US
Mailing Address - Phone:509-945-9818
Mailing Address - Fax:
Practice Address - Street 1:107 W NACHES AVE
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942-1323
Practice Address - Country:US
Practice Address - Phone:509-945-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018268247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other