Provider Demographics
NPI:1811976533
Name:GANNAN, ROBERT M (MD PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:GANNAN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 116TH AVE NE
Mailing Address - Street 2:560
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4623
Mailing Address - Country:US
Mailing Address - Phone:425-454-4768
Mailing Address - Fax:425-462-8021
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:560
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-454-4768
Practice Address - Fax:425-462-8021
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA16481207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA96596OtherL & I
WA1165208Medicaid
A04525Medicare UPIN
WA96596OtherL & I