Provider Demographics
NPI:1417086141
Name:GANUS, DARRELL LAYNE (MED, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:LAYNE
Last Name:GANUS
Suffix:
Gender:M
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 WOODLAWN ST
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3650
Mailing Address - Country:US
Mailing Address - Phone:903-983-3307
Mailing Address - Fax:903-983-3211
Practice Address - Street 1:301 N KILGORE ST
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-5825
Practice Address - Country:US
Practice Address - Phone:903-983-3307
Practice Address - Fax:903-983-3211
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer