=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093676496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUTUMN GIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2025
-----------------------------------------------------
Last Update Date | 11/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4409 W WADLEY AVE
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79707-5328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-617-3110
-----------------------------------------------------
Fax | 432-617-3112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 HANOVER DR
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-2239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-550-4700
-----------------------------------------------------
Fax | 432-550-4715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1407646
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------