Provider Demographics
NPI:1548950678
Name:GUNDERMAN, RYAN (FNP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GUNDERMAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-3957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 N 31ST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3957
Practice Address - Country:US
Practice Address - Phone:610-462-7954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027397363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner