Provider Demographics
NPI:1073726139
Name:GIBSON, PHILLIP GREGORY (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:GREGORY
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 990955
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-0955
Mailing Address - Country:US
Mailing Address - Phone:530-243-2164
Mailing Address - Fax:530-243-9446
Practice Address - Street 1:840 HARTNELL AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2118
Practice Address - Country:US
Practice Address - Phone:530-221-6584
Practice Address - Fax:530-221-8926
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06982PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT69820Medicare ID - Type Unspecified