Provider Demographics
NPI:1467263491
Name:GANNON, CARIN LIELA
Entity type:Individual
Prefix:
First Name:CARIN
Middle Name:LIELA
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 2ND AVE APT 4S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-8504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL # 1149
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:203-913-9582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant