Provider Demographics
NPI:1881897221
Name:GILSON, ROBERT WILLIAM (PTA, MT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:GILSON
Suffix:
Gender:M
Credentials:PTA, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11615 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1701
Mailing Address - Country:US
Mailing Address - Phone:602-616-5488
Mailing Address - Fax:
Practice Address - Street 1:6246 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1511
Practice Address - Country:US
Practice Address - Phone:602-433-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27A225200000X
MDA1923225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant