Provider Demographics
NPI:1821297508
Name:GIBSON, RAYMOND G (PTA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:G
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917B OPTIMIST DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-7794
Mailing Address - Country:US
Mailing Address - Phone:850-526-3067
Mailing Address - Fax:850-526-3086
Practice Address - Street 1:4230 LAFAYETTE ST STE C
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-8231
Practice Address - Country:US
Practice Address - Phone:850-526-1093
Practice Address - Fax:850-526-1803
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 1722225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant