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General NPI Number Information
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NPI Number | 1346705803
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Entity Type | Individual
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Provider Name | TIMOTHY GANNON PTA
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Gender | Male
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Dates
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Enumeration Date | 02/08/2019
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Last Update Date | 02/08/2019
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Provider Practice Location Address
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Address Line | 380 DEMOTT LN
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City | SOMERSET
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State | NJ
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Zip | 08873-2762
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Country | US
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Telephone | 800-571-6511
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 991
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City | MALAGA
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State | NJ
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Zip | 08328-0991
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Country | US
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Telephone | 865-278-7578
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 40QB00317700
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 40QB00317700
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License Number State | NJ
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