MEDICARE: TRACY FUCHS GANNON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	31837	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720053937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY FUCHS GANNON MD

Provider Business Mailing Address
First Line	:	2854 HIGHWAY 55
Second Line	:	SUITE 130
City	:	EAGAN
State	:	MN
Zip	:	55121-1447
Country	:	US
Telephone Number	:	651-224-4930
Fax Number	:	651-842-3391

Provider Business Practice Location Address
First Line	:	3640 TALMAGE CIRCLE
Second Line	:	SUITE 216
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-4183
Country	:	US
Telephone Number	:	651-224-4930
Fax Number	:	651-842-3391

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	06/03/2011

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