Basic Information
| Provider Information | |||||||||
| NPI: | 1790704856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2979 SQUALICUM PKWY | ||||||||
| Address2: | SUITE #203 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607337670 | ||||||||
| FaxNumber: | 3606471901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2979 SQUALICUM PKWY | ||||||||
| Address2: | SUITE #203 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607337670 | ||||||||
| FaxNumber: | 3606471901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | MD00021195 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | MD00021195 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.