Provider Demographics
NPI:1013389972
Name:GUNTER, NICHOLAS ALAN (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALAN
Last Name:GUNTER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-4232
Mailing Address - Country:US
Mailing Address - Phone:601-939-3030
Mailing Address - Fax:601-939-3042
Practice Address - Street 1:3825 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-4232
Practice Address - Country:US
Practice Address - Phone:601-939-3030
Practice Address - Fax:601-939-3042
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS453893ZRYNOtherMEDICARE PTAN
MS00538755Medicaid