Provider Demographics
NPI:1265635155
Name:GANGNIER, JENNIFER MARIE REISS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE REISS
Last Name:GANGNIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:REISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:43151 DALCOMA DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:866-790-6803
Practice Address - Street 1:2305 GENOA BUSINESS PARK DR
Practice Address - Street 2:SUITE 180
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7004
Practice Address - Country:US
Practice Address - Phone:810-355-4300
Practice Address - Fax:810-355-4967
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM92520003Medicare PIN