MEDICARE: MR. BONNIE KYGER GIBSON COTA

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	224Z00000X	Occupational Therapy Assistant	0131000188	VA

General Provider Information

NPI Number	:	1467755843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BONNIE KYGER GIBSON COTA

Provider Business Mailing Address
First Line	:	8042 PORT REPUBLIC RD
Second Line	:
City	:	PORT REPUBLIC
State	:	VA
Zip	:	24471-2652
Country	:	US
Telephone Number	:	540-249-8109
Fax Number	:

Provider Business Practice Location Address
First Line	:	8042 PORT REPUBLIC RD
Second Line	:
City	:	PORT REPUBLIC
State	:	VA
Zip	:	24471-2652
Country	:	US
Telephone Number	:	540-249-8109
Fax Number	:

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

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	12/07/2010

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