Provider Demographics
NPI:1083825905
Name:GIBBONS, MICHAEL (LMP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1413
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0204
Mailing Address - Country:US
Mailing Address - Phone:253-863-6378
Mailing Address - Fax:253-863-6429
Practice Address - Street 1:19102 STATE ROUTE 410 E STE A
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8449
Practice Address - Country:US
Practice Address - Phone:253-863-6378
Practice Address - Fax:253-863-6429
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013609225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4188GIOtherREGENCE