Provider Demographics
NPI:1285811935
Name:GIBBONS, PAMELA R (ATC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:R
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1005
Mailing Address - Country:US
Mailing Address - Phone:714-997-6640
Mailing Address - Fax:714-744-2161
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1005
Practice Address - Country:US
Practice Address - Phone:714-997-6640
Practice Address - Fax:714-744-2161
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
860020OtherNATA