Healthcare Provider Details

I. General information

NPI: 1780992024
Provider Name (Legal Business Name): TIM B GANNON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 ZAFARANO DR SUITE C
SANTA FE NM
87507-2669
US

IV. Provider business mailing address

3450 ZAFARANO DR SUITE C
SANTA FE NM
87507-2669
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-5885
  • Fax: 505-466-5886
Mailing address:
  • Phone: 505-466-5885
  • Fax: 505-466-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2010-0058
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: