1629078811 NPI number — THOMAS R. GANNON PA-C

Table of content: THOMAS R. GANNON PA-C (NPI 1629078811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629078811 NPI number — THOMAS R. GANNON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANNON
Provider First Name:
THOMAS
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1629078811
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:
PO BOX 660599
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75266-0599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-590-4105
Provider Business Mailing Address Fax Number:
214-590-4162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201 HARRY HINES BLVD
Provider Second Line Business Practice Location Address:
MEDICAL STAFF SERVICES
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75235-7708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-590-8006
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2005

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: 363A00000X , with the licence number:  PA04227 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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