Provider Demographics
NPI:1689684508
Name:GIBSON, WENDI S (DC)
Entity Type:Individual
Prefix:DR
First Name:WENDI
Middle Name:S
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1429
Mailing Address - Country:US
Mailing Address - Phone:610-265-2522
Mailing Address - Fax:610-265-3506
Practice Address - Street 1:645 CLARK AVE
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1429
Practice Address - Country:US
Practice Address - Phone:610-265-2522
Practice Address - Fax:610-265-3506
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003324L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA473798-RT2Medicare ID - Type Unspecified