Provider Demographics
NPI:1508631813
Name:GANN, MICHAEL ANDREW (CPSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:GANN
Suffix:
Gender:M
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N ALAMEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2590
Mailing Address - Country:US
Mailing Address - Phone:575-523-0111
Mailing Address - Fax:575-323-3046
Practice Address - Street 1:303 N ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2590
Practice Address - Country:US
Practice Address - Phone:575-523-0111
Practice Address - Fax:575-323-3046
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1598175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist