Basic Information
| Provider Information | |||||||||
| NPI: | 1003242298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANTNER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2750 NEWARK GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430239142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407889220 | ||||||||
| FaxNumber: | 7405228070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 NEWARK GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430239142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407889220 | ||||||||
| FaxNumber: | 7405228070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50-003782 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 50.003782 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.