Provider Demographics
NPI:1659352938
Name:GIBBONS, MATTHEW (PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W229N1416 WESTWOOD DR STE 4
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1309
Mailing Address - Country:US
Mailing Address - Phone:262-349-9297
Mailing Address - Fax:262-278-4062
Practice Address - Street 1:W229N1416 WESTWOOD DR STE 4
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1309
Practice Address - Country:US
Practice Address - Phone:262-349-9297
Practice Address - Fax:262-278-4062
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10389-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00231054OtherRAILROAD MEDICARE IND #
WI40455400Medicaid
WIP00231054OtherRAILROAD MEDICARE IND #