Provider Demographics
NPI:1588658140
Name:GAMBILL, ANTHONY W (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:W
Last Name:GAMBILL
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 JASMINE PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-3196
Mailing Address - Country:US
Mailing Address - Phone:260-483-3071
Mailing Address - Fax:
Practice Address - Street 1:2701 SPRING ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3939
Practice Address - Country:US
Practice Address - Phone:260-399-7700
Practice Address - Fax:260-399-8164
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000011A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer