Provider Demographics
NPI:1396121505
Name:GANTT, REGINA (CSFA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:GANTT
Suffix:
Gender:F
Credentials:CSFA
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Mailing Address - Street 1:28 VALLE LINDO ROAD
Mailing Address - Street 2:
Mailing Address - City:PERALTA
Mailing Address - State:NM
Mailing Address - Zip Code:87042
Mailing Address - Country:US
Mailing Address - Phone:505-280-5326
Mailing Address - Fax:505-848-5008
Practice Address - Street 1:28 VALLE LINDO ROAD
Practice Address - Street 2:
Practice Address - City:PERALTA
Practice Address - State:NM
Practice Address - Zip Code:87042
Practice Address - Country:US
Practice Address - Phone:505-280-5326
Practice Address - Fax:505-848-5008
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2016-01-13
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical