Provider Demographics
NPI:1891744199
Name:GUNTER, RUSSELL WAYNE (PT)
Entity Type:Individual
Prefix:PROF
First Name:RUSSELL
Middle Name:WAYNE
Last Name:GUNTER
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:PO BOX 61651
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70596-1651
Mailing Address - Country:US
Mailing Address - Phone:337-412-6146
Mailing Address - Fax:337-504-2884
Practice Address - Street 1:101 PARK WEST DR
Practice Address - Street 2:SUITE B
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-8902
Practice Address - Country:US
Practice Address - Phone:337-769-1556
Practice Address - Fax:337-769-1557
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H334CQ69Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER