MEDICARE: ANGELA MARIE GIBSON PTA

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	225200000X	Physical Therapy Assistant	22080	KS
2	225200000X	Physical Therapy Assistant	PTA22080	KS

General Provider Information

NPI Number	:	1437780285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA MARIE GIBSON PTA

Provider Business Mailing Address
First Line	:	164 W HEWETT RD
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-3310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	164 W HEWETT RD
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-3310
Country	:	US
Telephone Number	:	850-278-3821
Fax Number	:

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

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	01/30/2020

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