Provider Demographics
NPI:1679680417
Name:ANDRUS, GARY WYATT (AUD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WYATT
Last Name:ANDRUS
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 S DORA ST STE B2
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6353
Mailing Address - Country:US
Mailing Address - Phone:707-468-0400
Mailing Address - Fax:707-468-8240
Practice Address - Street 1:1165 S DORA ST STE B2
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6353
Practice Address - Country:US
Practice Address - Phone:707-468-0400
Practice Address - Fax:707-468-8240
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU902231H00000X
CAHA2025237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP119690OtherCALIFORNIA CHILDREN SRVCS
CAHA0020250Medicaid
CACGP119690OtherCALIFORNIA CHILDREN SRVCS