Provider Demographics
NPI:1841414836
Name:CANADA, GINA LYNN (DO)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:LYNN
Last Name:CANADA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 MEMORIAL BLVD STE B-1
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-1419
Mailing Address - Country:US
Mailing Address - Phone:724-628-3944
Mailing Address - Fax:724-628-3798
Practice Address - Street 1:2618 MEMORIAL BLVD STE B-1
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-1419
Practice Address - Country:US
Practice Address - Phone:724-628-3944
Practice Address - Fax:724-628-3798
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020549610001Medicaid
PA1020549610001Medicaid