Provider Demographics
NPI:1306364880
Name:GIBSON, GARRETT (PTA)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 ROUTE 394
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14710-9749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9520 FREDONIA STOCKTON RD
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-9518
Practice Address - Country:US
Practice Address - Phone:716-672-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010167-1225200000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant