Provider Demographics
NPI:1376882597
Name:GANN, BARRY
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:GANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:75 HIGHWAY 62 412 STE J
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9629
Practice Address - Country:US
Practice Address - Phone:870-994-7060
Practice Address - Fax:870-996-7063
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR195507795Medicaid