Provider Demographics
NPI:1841591138
Name:GREDECKI, PAWEL (PT)
Entity Type:Individual
Prefix:MR
First Name:PAWEL
Middle Name:
Last Name:GREDECKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 S LOCUST ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5789
Mailing Address - Country:US
Mailing Address - Phone:575-521-4296
Mailing Address - Fax:575-521-4494
Practice Address - Street 1:2404 S LOCUST ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5789
Practice Address - Country:US
Practice Address - Phone:575-521-4296
Practice Address - Fax:575-521-4494
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist