Healthcare Provider Details

I. General information

NPI: 1265044036
Provider Name (Legal Business Name): JOEL GUNDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W 52ND ST APT 2A
NEW YORK NY
10019-5637
US

IV. Provider business mailing address

411 W 52ND ST APT 2A
NEW YORK NY
10019-5637
US

V. Phone/Fax

Practice location:
  • Phone: 917-456-4704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number3243538953
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: