Provider Demographics
NPI:1174845259
Name:GIBSON, MARK ANTHONY II (DPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:GIBSON
Suffix:II
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1328
Mailing Address - Country:US
Mailing Address - Phone:606-783-6919
Mailing Address - Fax:606-783-6629
Practice Address - Street 1:1028 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1328
Practice Address - Country:US
Practice Address - Phone:606-783-6919
Practice Address - Fax:606-783-6629
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist