Provider Demographics
NPI:1821652694
Name:GANO, TARRYL JAMAL
Entity Type:Individual
Prefix:
First Name:TARRYL
Middle Name:JAMAL
Last Name:GANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PINE ST
Mailing Address - Street 2:
Mailing Address - City:EAST ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14445-1328
Mailing Address - Country:US
Mailing Address - Phone:585-353-1645
Mailing Address - Fax:
Practice Address - Street 1:120 PINE ST
Practice Address - Street 2:
Practice Address - City:EAST ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14445-1328
Practice Address - Country:US
Practice Address - Phone:585-353-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335064164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse