Basic Information
| Provider Information | |||||||||
| NPI: | 1972808327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILL | ||||||||
| FirstName: | GANNON | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886653 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 6160 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184944460 | ||||||||
| FaxNumber: | 9185023468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2011 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1950 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.