Healthcare Provider Details

I. General information

NPI: 1841952801
Provider Name (Legal Business Name): BRANDON GIBSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E 5TH AVE
ANTIGO WI
54409-2710
US

IV. Provider business mailing address

6355 N US HIGHWAY 23
SPRUCE MI
48762-9567
US

V. Phone/Fax

Practice location:
  • Phone: 715-623-9449
  • Fax:
Mailing address:
  • Phone: 989-464-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501020235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: