Basic Information
| Provider Information | |||||||||
| NPI: | 1922066331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | RITA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 LAKE DRIVE | ||||||||
| Address2: | STE 250 | ||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502662504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5158759925 | ||||||||
| FaxNumber: | 5158759923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 SW WHITE BIRCH CIRCLE | ||||||||
| Address2: | STE 111 | ||||||||
| City: | ANKENY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500237226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159647115 | ||||||||
| FaxNumber: | 5159647899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | T2006-010 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 03077 | IA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 03077 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 159949003 | 05 | AR | MEDICAID | 9170589 | 05 | IA | MEDICAID |