Provider Demographics
NPI:1023845054
Name:MILLSAPS, GANNON NEIL (PA-S)
Entity type:Individual
Prefix:MR
First Name:GANNON
Middle Name:NEIL
Last Name:MILLSAPS
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-8256
Mailing Address - Country:US
Mailing Address - Phone:704-873-6515
Mailing Address - Fax:
Practice Address - Street 1:2603 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8256
Practice Address - Country:US
Practice Address - Phone:704-873-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program