Provider Demographics
NPI:1215417266
Name:LANDERMAN, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:LANDERMAN
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 1:3404 ROCK RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-3238
Mailing Address - Country:US
Mailing Address - Phone:740-586-5539
Mailing Address - Fax:
Practice Address - Street 1:451 S EL CAMINO XING
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-1666
Practice Address - Country:US
Practice Address - Phone:936-275-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT208166225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant