Healthcare Provider Details

I. General information

NPI: 1164491908
Provider Name (Legal Business Name): GARY DAVID WEBSKOWSKI MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

V. Phone/Fax

Practice location:
  • Phone: 952-806-5619
  • Fax: 952-806-5510
Mailing address:
  • Phone: 952-806-5619
  • Fax: 952-806-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number6090
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: