MEDICARE: MEGAN LEE GIBSON ATC

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	2255A2300X	Athletic Trainer	RT004591	PA

General Provider Information

NPI Number	:	1134352644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN LEE GIBSON ATC

Provider Business Mailing Address
First Line	:	2983 CHERRY GROVE RD
Second Line	:
City	:	YANCEYVILLE
State	:	NC
Zip	:	27379-9196
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2983 CHERRY GROVE RD
Second Line	:
City	:	YANCEYVILLE
State	:	NC
Zip	:	27379-9196
Country	:	US
Telephone Number	:	336-421-9868
Fax Number	:

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

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	08/31/2009

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