Provider Demographics
NPI:1972170827
Name:GAMBLIN, TABOR WESLEY (DPT)
Entity Type:Individual
Prefix:
First Name:TABOR
Middle Name:WESLEY
Last Name:GAMBLIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4743 S WACO AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-7844
Mailing Address - Country:US
Mailing Address - Phone:504-600-2063
Mailing Address - Fax:
Practice Address - Street 1:11420 BLONDO ST STE 103
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3858
Practice Address - Country:US
Practice Address - Phone:402-509-5532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist