Healthcare Provider Details

I. General information

NPI: 1609886456
Provider Name (Legal Business Name): KENNETH WINSTON GASAWAY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 BUCKINGHAM RD ABSS, C/O ANDREWS ELEMENTARY
BURLINGTON NC
27217-3252
US

IV. Provider business mailing address

3111 HARRISON CT
BURLINGTON NC
27215-6285
US

V. Phone/Fax

Practice location:
  • Phone: 336-570-6644
  • Fax:
Mailing address:
  • Phone: 336-221-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9071
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: