Healthcare Provider Details

I. General information

NPI: 1003644428
Provider Name (Legal Business Name): CAMILLE GANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 100 YEARPARTY CT # 80504
LONGMONT CO
80504-8475
US

IV. Provider business mailing address

220 WRIGHT ST APT 203
LAKEWOOD CO
80228-1409
US

V. Phone/Fax

Practice location:
  • Phone: 303-848-3800
  • Fax:
Mailing address:
  • Phone: 715-781-0949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: