Healthcare Provider Details

I. General information

NPI: 1053805671
Provider Name (Legal Business Name): JEREMY GANZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 01/22/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W D. L. INGRAM AVENUE, BLDG. 1408
CLOVIS NM
88103
US

IV. Provider business mailing address

27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W D. L. INGRAM AVENUE, BLDG. 1408
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: