Provider Demographics
NPI:1447512819
Name:FANNON, GARY (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:FANNON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 HURLEY PLZ
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5902
Mailing Address - Country:US
Mailing Address - Phone:810-262-9683
Mailing Address - Fax:810-760-0440
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9683
Practice Address - Fax:810-760-0440
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical