Provider Demographics
NPI:1750421806
Name:FANN, GLORIA M (MD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:FANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:130 SUTTER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-4009
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:415-520-0904
Practice Address - Street 1:1600 7TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2288
Practice Address - Country:US
Practice Address - Phone:206-267-4390
Practice Address - Fax:206-267-4391
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2018-12-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00045842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8467078Medicaid
WA8467078Medicaid