Provider Demographics
NPI:1164677787
Name:GANNON, LINDSAY L (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:L
Last Name:GANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:L
Other - Last Name:FORWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3515 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0711
Mailing Address - Country:US
Mailing Address - Phone:903-831-7270
Mailing Address - Fax:903-793-0496
Practice Address - Street 1:1910 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-2715
Practice Address - Country:US
Practice Address - Phone:732-531-0100
Practice Address - Fax:732-531-0144
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00205100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant