Provider Demographics
NPI:1245499052
Name:GANNON, KELLY (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2440 CENTURY PL SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4031
Mailing Address - Country:US
Mailing Address - Phone:828-431-5600
Mailing Address - Fax:828-431-5697
Practice Address - Street 1:1100 TUNNEL RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2576
Practice Address - Country:US
Practice Address - Phone:828-431-5600
Practice Address - Fax:828-431-5600
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS011182207Q00000X
PAOS13999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA129394Medicare PIN