Provider Demographics
NPI:1386053585
Name:GARDUNO, JHONNATAN (PA-C)
Entity type:Individual
Prefix:
First Name:JHONNATAN
Middle Name:
Last Name:GARDUNO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 INTERSTATE 30, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:972-216-5400
Mailing Address - Fax:
Practice Address - Street 1:3228 INTERSTATE 30, SUITE 200
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:972-216-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant