Provider Demographics
NPI:1790747426
Name:GANNON, PATRICK RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:RUSSELL
Last Name:GANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1245 S UTICA AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4214
Mailing Address - Country:US
Mailing Address - Phone:918-579-2300
Mailing Address - Fax:918-579-2309
Practice Address - Street 1:1 E CLARK BASS BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4209
Practice Address - Country:US
Practice Address - Phone:918-421-6987
Practice Address - Fax:918-421-6698
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20652207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK74502A024OtherCHAMPUS
OKG67583OtherSTERLING OPTION 1
OK1000176970AMedicaid
OK731310891006OtherUNICARE
OK1324230001OtherPALMETTO DME
OK731310891028OtherTRICARE SOUTH
OK0166707OtherUMWA
OK731310891028OtherTRICARE SOUTH
OKG67583Medicare UPIN