Provider Demographics
NPI:1780992024
Name:GANNON, TIM B (PA)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:B
Last Name:GANNON
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3450 ZAFARANO DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-2669
Mailing Address - Country:US
Mailing Address - Phone:505-466-5885
Mailing Address - Fax:505-466-5886
Practice Address - Street 1:3450 ZAFARANO DR
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2669
Practice Address - Country:US
Practice Address - Phone:505-466-5885
Practice Address - Fax:505-466-5886
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2013-10-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2010-0058363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25773119Medicaid
NMNMA101086Medicare PIN