Healthcare Provider Details

I. General information

NPI: 1134793169
Provider Name (Legal Business Name): GANNON RYAN NYQUIST PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CLUB DR
VALLEJO CA
94592-1187
US

IV. Provider business mailing address

624 N CASCADE AVE APT 41
COLORADO SPRINGS CO
80903-3225
US

V. Phone/Fax

Practice location:
  • Phone: 707-638-5809
  • Fax:
Mailing address:
  • Phone: 505-280-0158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA213297
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: