Provider Demographics
NPI:1962371161
Name:GANNOTTA, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GANNOTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 FELSPAR WAY
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-2204
Mailing Address - Country:US
Mailing Address - Phone:919-518-7941
Mailing Address - Fax:
Practice Address - Street 1:413 FELSPAR WAY
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-2204
Practice Address - Country:US
Practice Address - Phone:919-518-7941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900107363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health