Provider Demographics
NPI:1174060347
Name:GANNON, BRYCE (BS)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:GANNON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 W OWEN K GARRIOTT RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-5653
Mailing Address - Country:US
Mailing Address - Phone:580-242-4673
Mailing Address - Fax:
Practice Address - Street 1:1625 W OWEN K GARRIOTT RD
Practice Address - Street 2:SUITE F
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5653
Practice Address - Country:US
Practice Address - Phone:580-242-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator