Provider Demographics
NPI:1588764245
Name:GANNON, BLAZE RYAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:BLAZE
Middle Name:RYAN
Last Name:GANNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W LUGONIA AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-9705
Mailing Address - Country:US
Mailing Address - Phone:909-557-1600
Mailing Address - Fax:909-557-1740
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:ORTHOPAEDIC ADMIN
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant