Healthcare Provider Details

I. General information

NPI: 1477220093
Provider Name (Legal Business Name): GINA RENEE GANO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W MAIN ST
SPRINGFIELD OH
45502-1368
US

IV. Provider business mailing address

2143 CHAPEL DR
FAIRBORN OH
45324-6430
US

V. Phone/Fax

Practice location:
  • Phone: 937-342-3130
  • Fax:
Mailing address:
  • Phone: 937-869-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number50.007112RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: