Provider Demographics
NPI:1922208024
Name:GANZ, BECKY J (ANP)
Entity Type:Individual
Prefix:MS
First Name:BECKY
Middle Name:J
Last Name:GANZ
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8056
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-1171
Mailing Address - Fax:314-362-3192
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:7TH FLOOR
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-1171
Practice Address - Fax:314-362-3192
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO149360363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO426315602Medicaid
MO426315602Medicaid
IL$$$$$$$$$001Medicaid