Provider Demographics
NPI:1073215240
Name:GANUGAPENTA, KIRAN KUMAR
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:KUMAR
Last Name:GANUGAPENTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10669 SKY CHASE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-2622
Mailing Address - Country:US
Mailing Address - Phone:989-760-1028
Mailing Address - Fax:
Practice Address - Street 1:10669 SKY CHASE AVE NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-2622
Practice Address - Country:US
Practice Address - Phone:989-760-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist