Basic Information
| Provider Information | |||||||||
| NPI: | 1790747426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 S UTICA AVE | ||||||||
| Address2: | FL 2 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185792300 | ||||||||
| FaxNumber: | 9185792309 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 E CLARK BASS BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184216987 | ||||||||
| FaxNumber: | 9184216698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 20652 | OK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 74502A024 | 01 | OK | CHAMPUS | OTHER | G67583 | 01 | OK | STERLING OPTION 1 | OTHER | 1000176970A | 05 | OK | MEDICAID | 731310891006 | 01 | OK | UNICARE | OTHER | 1324230001 | 01 | OK | PALMETTO DME | OTHER | 731310891028 | 01 | OK | TRICARE SOUTH | OTHER | 0166707 | 01 | OK | UMWA | OTHER |