Provider Demographics
NPI:1356706907
Name:MARSH, GANNON BRADLEY (FNP)
Entity type:Individual
Prefix:
First Name:GANNON
Middle Name:BRADLEY
Last Name:MARSH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MEDICAL CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-9004
Mailing Address - Country:US
Mailing Address - Phone:903-676-1144
Mailing Address - Fax:
Practice Address - Street 1:115 MEDICAL CIR STE 100
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-9004
Practice Address - Country:US
Practice Address - Phone:903-676-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily