Provider Demographics
NPI:1679646749
Name:GIBSON, MARK H (LAT, PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:H
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LAT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 SILVER MORNING LN
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-2283
Mailing Address - Country:US
Mailing Address - Phone:608-788-3972
Mailing Address - Fax:
Practice Address - Street 1:1725 STATE ST
Practice Address - Street 2:UNIV. OF WISCONSIN - LA CROSSE
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3742
Practice Address - Country:US
Practice Address - Phone:608-785-8190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4707-024225100000X
WI404-039225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist