Provider Demographics
NPI:1558876110
Name:GIBSON, DANIEL (LAT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22539 VALLEY CANYON LN
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-7414
Mailing Address - Country:US
Mailing Address - Phone:936-327-2031
Mailing Address - Fax:
Practice Address - Street 1:22539 VALLEY CANYON LN
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-7414
Practice Address - Country:US
Practice Address - Phone:936-327-2031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT50122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT5012OtherLICENSED ATHLETIC TRAINER