Provider Demographics
NPI:1104836063
Name:GANG, ANN M (NP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:GANG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-1551
Mailing Address - Country:US
Mailing Address - Phone:317-621-9220
Mailing Address - Fax:317-621-9222
Practice Address - Street 1:717 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-1551
Practice Address - Country:US
Practice Address - Phone:317-621-9220
Practice Address - Fax:317-621-9222
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000302A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS85809Medicare UPIN
IN230240BMedicare PIN
INM400033992Medicare PIN