Provider Demographics
NPI:1982186342
Name:GIBBS, MATTHEW MACKINNON
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MACKINNON
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS IS
Mailing Address - State:GA
Mailing Address - Zip Code:31522
Mailing Address - Country:US
Mailing Address - Phone:912-580-9811
Mailing Address - Fax:
Practice Address - Street 1:211 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ST SIMONS IS
Practice Address - State:GA
Practice Address - Zip Code:31522
Practice Address - Country:US
Practice Address - Phone:912-580-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-02
Last Update Date:2018-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer