Basic Information
| Provider Information | |||||||||
| NPI: | 1013389972 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUNTER | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3825 HIGHWAY 80 E | ||||||||
| Address2: | |||||||||
| City: | PEARL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392084232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019393030 | ||||||||
| FaxNumber: | 6019393042 | ||||||||
| Practice Location | |||||||||
| Address1: | 3825 HIGHWAY 80 E | ||||||||
| Address2: | |||||||||
| City: | PEARL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392084232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019393030 | ||||||||
| FaxNumber: | 6019393042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2015 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5727 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 453893ZRYN | 01 | MS | MEDICARE PTAN | OTHER | 00538755 | 05 | MS | MEDICAID |