Provider Demographics
NPI:1225589260
Name:GIBSON, JAMES ELON (ATC, LAT, LP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ELON
Last Name:GIBSON
Suffix:
Gender:M
Credentials:ATC, LAT, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 COLLEGE MAIN
Mailing Address - Street 2:SUITE 129
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-1601
Mailing Address - Country:US
Mailing Address - Phone:979-571-8551
Mailing Address - Fax:
Practice Address - Street 1:418 COLLEGE MAIN
Practice Address - Street 2:SUITE 129
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-1601
Practice Address - Country:US
Practice Address - Phone:979-571-8551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94273146L00000X
TXAT22162255A2300X
NE0201021082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic