Provider Demographics
NPI:1073710778
Name:GANONG, CARRIE ATWELL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:ATWELL
Last Name:GANONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:3001 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1114
Practice Address - Country:US
Practice Address - Phone:541-851-4800
Practice Address - Fax:541-851-4801
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR44131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64958960Medicaid
CO01325653Medicaid
KY64958960Medicaid