Healthcare Provider Details

I. General information

NPI: 1265122444
Provider Name (Legal Business Name): TONY GIBSON HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 W RIDGEVIEW DR STE 2
APPLETON WI
54911-1254
US

IV. Provider business mailing address

654 W RIDGEVIEW DR STE 2
APPLETON WI
54911-1254
US

V. Phone/Fax

Practice location:
  • Phone: 920-364-9791
  • Fax: 920-968-9315
Mailing address:
  • Phone: 920-968-9315
  • Fax: 920-968-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2014-060
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: