Provider Demographics
NPI:1700061678
Name:GIBLIN, SHANE M (PTA)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:M
Last Name:GIBLIN
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 1:7485 MISSION VALLEY RD
Mailing Address - Street 2:SUITE 104 A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4422
Mailing Address - Country:US
Mailing Address - Phone:619-291-8930
Mailing Address - Fax:619-398-4989
Practice Address - Street 1:7485 MISSION VALLEY RD
Practice Address - Street 2:SUITE 104 A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4422
Practice Address - Country:US
Practice Address - Phone:619-291-8930
Practice Address - Fax:619-398-4989
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant