Provider Demographics
NPI:1407112725
Name:PADNUK, ANDREW SERGE
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:SERGE
Last Name:PADNUK
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 1:8421 CASA DEL RIO LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1606
Mailing Address - Country:US
Mailing Address - Phone:239-851-8900
Mailing Address - Fax:
Practice Address - Street 1:8421 CASA DEL RIO LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1606
Practice Address - Country:US
Practice Address - Phone:239-851-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist