Provider Demographics
NPI:1952697781
Name:GIBSON, MICHAEL RYAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RYAN
Last Name:GIBSON
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 1:122 SANDSTONE DR APT 12
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2843
Mailing Address - Country:US
Mailing Address - Phone:304-923-2427
Mailing Address - Fax:
Practice Address - Street 1:122 SANDSTONE DR APT 12
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2843
Practice Address - Country:US
Practice Address - Phone:304-923-2427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001632225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant