Provider Demographics
NPI:1609173467
Name:GIBBONS, RYAN (LMT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 NW 173RD AVE
Mailing Address - Street 2:103
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3563
Mailing Address - Country:US
Mailing Address - Phone:503-330-1171
Mailing Address - Fax:
Practice Address - Street 1:2155 NW 173RD AVE
Practice Address - Street 2:103
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-330-1117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10908174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist