Provider Demographics
NPI:1205362571
Name:GANNON, EDWIN WENDELL III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:WENDELL
Last Name:GANNON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WYN
Other - Middle Name:
Other - Last Name:GANNON
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:UNIVERSITY OF TENNESSEE
Mailing Address - Street 2:920 MADISON AVENUE SUITE 447
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38163-0001
Mailing Address - Country:US
Mailing Address - Phone:901-448-5814
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF TENNESSEE
Practice Address - Street 2:920 MADISON AVENUE SUITE 447
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-5814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program