Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH4236 | FL |
NPI | 1417061268 |
---|---|
Provider Name | Brian C Gibson |
First Address | Venice, FL 34285-5572 |
Second Address | Venice, FL 34285-5572 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2006 |
Last Update Date | 10/10/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T73194 | (02) | FL |
U4228 | MEDICARE PTAN (01) | FL |