Individual
MR. BLAZE RYAN GANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
400 N PEPPER AVE, ORTHOPAEDIC ADMIN, COLTON, CA 92324-1801
(909) 580-6330
Mailing address
1901 W LUGONIA AVE STE 230, REDLANDS, CA 92374-9705
(909) 557-1600
(909) 557-1740
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA18462
CA
Other
Enumeration date
09/23/2006
Last updated
02/08/2010
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