Basic Information
| Provider Information | |||||||||
| NPI: | 1003012733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WORTH | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | C. | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1450 TREAT BLVD # 300 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259522828 | ||||||||
| FaxNumber: | 6199064623 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 PLEASANT HILL RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945232033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256761700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A105771 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | A105771 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.