Provider Demographics
NPI:1750027280
Name:GANUNG, ANDREW GRAYSON (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:GRAYSON
Last Name:GANUNG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 RIVERSIDE AVE STE 190
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4189
Mailing Address - Country:US
Mailing Address - Phone:904-647-4284
Mailing Address - Fax:
Practice Address - Street 1:1045 RIVERSIDE AVE STE 190
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4189
Practice Address - Country:US
Practice Address - Phone:904-647-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist