Provider Demographics
NPI:1588037253
Name:GANCEDO, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GANCEDO
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 1:4125 S TAMIAMI TRL STE 2
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5121
Mailing Address - Country:US
Mailing Address - Phone:941-584-9201
Mailing Address - Fax:941-584-9202
Practice Address - Street 1:4125 S TAMIAMI TRL STE 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5121
Practice Address - Country:US
Practice Address - Phone:941-584-9201
Practice Address - Fax:941-584-9202
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9383141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily