Basic Information
| Provider Information | |||||||||
| NPI: | 1962638080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANS | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | JENNIFER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3535 PENTAGON BLVD STE 330 | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454311705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958556 | ||||||||
| FaxNumber: | 9373956376 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 PENTAGON BLVD STE 330 | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454311705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958556 | ||||||||
| FaxNumber: | 9373956376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35.097120 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 35.097120 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 0111981 | 05 | OH | MEDICAID |