Provider Demographics
NPI:1922567791
Name:WARD, GANNON O (DC)
Entity Type:Individual
Prefix:DR
First Name:GANNON
Middle Name:O
Last Name:WARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 E 12300 S STE C
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8043
Mailing Address - Country:US
Mailing Address - Phone:801-849-1029
Mailing Address - Fax:801-890-0513
Practice Address - Street 1:392 E 12300 S STE C
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8043
Practice Address - Country:US
Practice Address - Phone:801-849-1029
Practice Address - Fax:801-890-0513
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11172962-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11172962-1202OtherUTAH CHIROPRACTIC LICENSE NUMBER