Provider Demographics
NPI:1770182404
Name:GANNON, PAUL (ND)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:GANNON
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3056
Mailing Address - Country:US
Mailing Address - Phone:305-491-9209
Mailing Address - Fax:
Practice Address - Street 1:6100 219TH ST SW STE 480
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2222
Practice Address - Country:US
Practice Address - Phone:212-390-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001001175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath