MEDICARE: VINCE A GILDNER JR. PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	602183250	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	158090	OTHER	VA	L&I INDIVIDUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8610GI	OTHER	WA	REGENCE INDIVIDUAL

General Provider Information

NPI Number	:	1396746418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCE A GILDNER JR. PT

Provider Business Mailing Address
First Line	:	111 TUMWATER BLVD SE
Second Line	:	SUITE 113
City	:	TUMWATER
State	:	WA
Zip	:	98501-6400
Country	:	US
Telephone Number	:	360-528-3300
Fax Number	:	360-528-8162

Provider Business Practice Location Address
First Line	:	111 TUMWATER BLVD SE
Second Line	:	SUITE 113
City	:	TUMWATER
State	:	WA
Zip	:	98501-6400
Country	:	US
Telephone Number	:	360-528-3300
Fax Number	:	360-528-8162

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	09/12/2012

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