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General NPI Number Information
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NPI Number | 1689246589
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Entity Type | Individual
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Provider Name | JEREMY NEAL GANNON CRNA
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Gender | Male
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Dates
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Enumeration Date | 07/12/2021
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Last Update Date | 06/09/2026
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Provider Practice Location Address
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Address Line | 501 MORRIS ST
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City | CHARLESTON
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State | WV
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Zip | 25301-1326
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Country | US
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Telephone | 304-388-5432
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Fax |
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Provider Business Mailing Address
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Address Line | 810 LAKEVIEW DR
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City | CROSS LANES
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State | WV
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Zip | 25313-1448
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Country | US
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Telephone | 304-543-9433
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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 | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 110057
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License Number State | WV
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