Provider Demographics
NPI:1922136142
Name:GANNON, GREGORY LEE (APN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:GANNON
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 LANA RENEE CT
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3203
Mailing Address - Country:US
Mailing Address - Phone:615-519-5634
Mailing Address - Fax:
Practice Address - Street 1:1921 RANSOM PL
Practice Address - Street 2:CENTERSTONE FRANK LUTON CENTER
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37217-3841
Practice Address - Country:US
Practice Address - Phone:615-279-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN8456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ48966Medicare UPIN
3640680Medicare ID - Type Unspecified