Healthcare Provider Details

I. General information

NPI: 1831293216
Provider Name (Legal Business Name): LUCILLE GANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11728 - 139 AVENUE NW
EDMONTON ALBERTA
T5X 3P3
CA

IV. Provider business mailing address

11728 - 139 AVENUE NW
EDMONTON ALBERTA
T5X 3P3
CA

V. Phone/Fax

Practice location:
  • Phone: 780-461-8456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number74799
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: