Provider Demographics
NPI:1659502862
Name:GIBSON, NATHAN JOHN (PT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOHN
Last Name:GIBSON
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 1:2086 VADALABENE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-7150
Mailing Address - Fax:618-288-7160
Practice Address - Street 1:2086 VADALABENE DRIVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-7150
Practice Address - Fax:618-288-7160
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist