Provider Demographics
NPI:1407373640
Name:GUNDRY, GARRETT RYAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:RYAN
Last Name:GUNDRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12002 N 5600 W
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:UT
Mailing Address - Zip Code:84308-1712
Mailing Address - Country:US
Mailing Address - Phone:208-380-0251
Mailing Address - Fax:
Practice Address - Street 1:115 GOLF COURSE RD STE E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5934
Practice Address - Country:US
Practice Address - Phone:435-999-4059
Practice Address - Fax:435-213-2800
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12819884-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical