1194721241 NPI number — DR. JENNIFER SAKURA GANNON OD, FAAO

Table of content: DR. JENNIFER SAKURA GANNON OD, FAAO (NPI 1194721241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194721241 NPI number — DR. JENNIFER SAKURA GANNON OD, FAAO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANNON
Provider First Name:
JENNIFER
Provider Middle Name:
SAKURA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD, FAAO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194721241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 HALL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUT BANK
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59427-9220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-336-2657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLACKFEET COMMUNITY HOSPITAL EYE CLINIC
Provider Second Line Business Practice Location Address:
HOPSITAL CIRCLE
Provider Business Practice Location Address City Name:
BROWNING
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-338-6140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  233 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)