Provider Demographics
NPI:1659714913
Name:HANNON, GREGORY RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:RUSSELL
Last Name:HANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:RUSSELL
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3316 WEST 66TH ST
Mailing Address - Street 2:#200
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-920-3808
Mailing Address - Fax:
Practice Address - Street 1:3316 W 66TH ST STE 200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2544
Practice Address - Country:US
Practice Address - Phone:952-303-8600
Practice Address - Fax:952-920-8899
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN59142207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program