Provider Demographics
NPI:1942365077
Name:GANNON, AIMEE L (PA)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:L
Last Name:GANNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:5900 LAKE WRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1871
Mailing Address - Country:US
Mailing Address - Phone:757-466-8683
Mailing Address - Fax:757-466-8892
Practice Address - Street 1:300 MEDICAL PKWY
Practice Address - Street 2:SUITE 314
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4985
Practice Address - Country:US
Practice Address - Phone:757-549-4403
Practice Address - Fax:757-549-4332
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2010-05-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1942365077OtherHEALTH NET TRICARE
VA1942365077Medicaid
VA1942365077OtherOPTIMA
VA1942365077OtherHEALTH NET TRICARE