Healthcare Provider Details

I. General information

NPI: 1487117214
Provider Name (Legal Business Name): NICHOLAS PATRICK GANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/27/2025
Certification Date: 04/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 OWENS ST
SAN FRANCISCO CA
94158-2334
US

IV. Provider business mailing address

500 PARNASSUS AVE # MU320W
SAN FRANCISCO CA
94143-2203
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-2808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA194103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: