Provider Demographics
NPI:1629435946
Name:SCANNON, PATRICK JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JEROME
Last Name:SCANNON
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 1:176 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3713
Mailing Address - Country:US
Mailing Address - Phone:510-599-2538
Mailing Address - Fax:
Practice Address - Street 1:176 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-3713
Practice Address - Country:US
Practice Address - Phone:510-599-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-16
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG36339OtherCALIFORNIA MEDICAL LICENSE
BS7916185OtherDEA REGISTRATION NUMBER