MEDICARE: AMY GIBSON ATC LAT

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	390200000X	Student in an Organized Health Care Education/Training Program	1299	AZ

General Provider Information

NPI Number	:	1356759393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY GIBSON ATC LAT

Provider Business Mailing Address
First Line	:	4776 E GUADALUPE RD
Second Line	:	APT 2045
City	:	GILBERT
State	:	AZ
Zip	:	85234-7501
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7050 S 24TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-5806
Country	:	US
Telephone Number	:	602-243-8232
Fax Number	:

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

Provider Enumeration Date	:	07/22/2014
Last Update Date	:	07/22/2014

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