Provider Demographics
NPI:1578000220
Name:GANTT, CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:GANTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10452 HAZELTON ETNA RD SW
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-3400
Mailing Address - Country:US
Mailing Address - Phone:668-639-3659
Mailing Address - Fax:414-622-3903
Practice Address - Street 1:10452 HAZELTON ETNA RD SW
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:OH
Practice Address - Zip Code:43062-3400
Practice Address - Country:US
Practice Address - Phone:866-639-3659
Practice Address - Fax:414-622-3903
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004763RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant