Provider Demographics
NPI:1871837898
Name:GIBSON, KORTNIE BRYANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KORTNIE
Middle Name:BRYANNE
Last Name:GIBSON
Suffix:
Gender:F
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:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-0383
Mailing Address - Country:US
Mailing Address - Phone:660-438-6993
Mailing Address - Fax:
Practice Address - Street 1:1111 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-2005
Practice Address - Country:US
Practice Address - Phone:660-632-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008035475225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant