Provider Demographics
NPI:1659477693
Name:GENTRY, GARY DALTON (APRN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DALTON
Last Name:GENTRY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4500 13TH STREET
Mailing Address - Street 2:WOUND CARE
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:228-867-4499
Mailing Address - Fax:228-867-5027
Practice Address - Street 1:4500 13TH STREET
Practice Address - Street 2:WOUND CARE
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-867-4499
Practice Address - Fax:228-867-5027
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS607576363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05489238Medicaid