Provider Demographics
NPI:1447753140
Name:GIBSON, ADAM (ATC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 S 100 W
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:IN
Mailing Address - Zip Code:46928-9228
Mailing Address - Country:US
Mailing Address - Phone:765-206-1042
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1018
Practice Address - Country:US
Practice Address - Phone:765-206-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002944A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer