Provider Demographics
NPI:1841952801
Name:GIBSON, BRANDON (DPT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GIBSON
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 1:6355 N US HIGHWAY 23
Mailing Address - Street 2:
Mailing Address - City:SPRUCE
Mailing Address - State:MI
Mailing Address - Zip Code:48762-9567
Mailing Address - Country:US
Mailing Address - Phone:989-464-2704
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-9449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501020235225100000X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist