Provider Demographics
NPI:1194077636
Name:GRESHAM, ANNA PEARSON (FNP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:PEARSON
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3417 GASTON AVE.
Mailing Address - Street 2:SUITE 700
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246
Mailing Address - Country:US
Mailing Address - Phone:601-624-2662
Mailing Address - Fax:214-823-4801
Practice Address - Street 1:3417 GASTON AVENUE
Practice Address - Street 2:SUITE 700
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-823-4800
Practice Address - Fax:214-823-4801
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX842113363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3276743-01Medicaid
TX3276743-01Medicaid