Provider Demographics
NPI:1790704856
Name:GANNON, MICHAEL KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEVIN
Last Name:GANNON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2979 SQUALICUM PKWY
Mailing Address - Street 2:SUITE #203
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1811
Mailing Address - Country:US
Mailing Address - Phone:360-733-7670
Mailing Address - Fax:360-647-1901
Practice Address - Street 1:2979 SQUALICUM PKWY
Practice Address - Street 2:SUITE #203
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1811
Practice Address - Country:US
Practice Address - Phone:360-733-7670
Practice Address - Fax:360-647-1901
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-02-01
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Provider Licenses
StateLicense IDTaxonomies
WAMD00021195207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB23292Medicare PIN
WAF23204Medicare UPIN