Provider Demographics
NPI:1598981763
Name:GANT, KATHRYN BOYSE (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BOYSE
Last Name:GANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELISE
Other - Last Name:BOYSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:258 GIBSON DR
Mailing Address - Street 2:STE 140
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5881
Mailing Address - Country:US
Mailing Address - Phone:916-755-0077
Mailing Address - Fax:916-755-0099
Practice Address - Street 1:258 GIBSON DR
Practice Address - Street 2:STE 140
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5881
Practice Address - Country:US
Practice Address - Phone:916-755-0077
Practice Address - Fax:916-755-0099
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090979207N00000X
OH57.012401207N00000X
CA123615207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00824293OtherRAILROAD MEDICARE
OH000000610931OtherANTHEM BC/BS
OHP00824293OtherRAILROAD MEDICARE