Provider Demographics
NPI:1174993711
Name:GANNUTZ, SEAN P (PA-C)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:P
Last Name:GANNUTZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:151 JOHNSTOWN DR
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9366
Practice Address - Country:US
Practice Address - Phone:417-269-2252
Practice Address - Fax:417-269-2259
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid