MEDICARE: AUSTIN CLARK GIBBS PT, DPT

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	65957	OR

General Provider Information

NPI Number	:	1417483116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUSTIN CLARK GIBBS PT, DPT

Provider Business Mailing Address
First Line	:	4843 VERDA LN NE APT 202
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-2364
Country	:	US
Telephone Number	:	503-583-4017
Fax Number	:

Provider Business Practice Location Address
First Line	:	4843 VERDA LN NE APT 202
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-2364
Country	:	US
Telephone Number	:	503-583-4017
Fax Number	:

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

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	01/20/2026

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