Provider Demographics
NPI:1417191412
Name:GANNON, REYNALDO TIONGSON (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:TIONGSON
Last Name:GANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2338
Mailing Address - Country:US
Mailing Address - Phone:814-535-6312
Mailing Address - Fax:812-535-5136
Practice Address - Street 1:510 WAYNE ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2338
Practice Address - Country:US
Practice Address - Phone:814-535-6312
Practice Address - Fax:812-535-5136
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA031303-L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology