Provider Demographics
NPI:1043242662
Name:GARTUNG, JOHN A JR (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:GARTUNG
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3520
Mailing Address - Country:US
Mailing Address - Phone:803-256-4107
Mailing Address - Fax:803-254-2825
Practice Address - Street 1:1910 BLANDING ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3520
Practice Address - Country:US
Practice Address - Phone:803-256-4107
Practice Address - Fax:803-254-2825
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1672363AS0400X
SCTL1672363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1242PAMedicaid
SC1242PAMedicaid