Provider Demographics
NPI:1104838325
Name:GAMMON, CHRISTOPHER D (OTR)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
Last Name:GAMMON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N ROBBINS RD
Mailing Address - Street 2:STE 401
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4566
Mailing Address - Country:US
Mailing Address - Phone:208-383-0201
Mailing Address - Fax:208-489-4249
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4566
Practice Address - Country:US
Practice Address - Phone:208-383-0201
Practice Address - Fax:208-489-4249
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OT-6572251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1655913OtherHUMANA
IDW0988OtherBLUE CROSS OF IDAHO
IDP00181938OtherMEDICARE RAILROAD
ID1655913Medicare ID - Type Unspecified