Provider Demographics
NPI:1164509865
Name:GAUNTT, TONY I (PA)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:I
Last Name:GAUNTT
Suffix:
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:PO BOX 2509
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78627-2509
Mailing Address - Country:US
Mailing Address - Phone:512-868-0901
Mailing Address - Fax:512-868-1527
Practice Address - Street 1:908 ROCKMOOR DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8966
Practice Address - Country:US
Practice Address - Phone:512-868-0901
Practice Address - Fax:512-868-1527
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA00247OtherPHYSICIAN'S ASST LICENSE
TXS69628Medicare UPIN
TX82N446Medicare ID - Type Unspecified