Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 21979 | MA |
NPI | 1003284001 |
---|---|
Provider Name | Benjamin Gibson |
First Address | Boston, MA 02215-2099 |
Second Address | Arlington, MA 02474-8705 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2015 |
Last Update Date | 11/09/2015 |