Individual
TIM B GANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
649 HARKLE RD STE E, SANTA FE, NM 87505-4765
(505) 955-9454
(505) 216-9067
Mailing address
PO BOX 6880, SANTA FE, NM 87502-6880
(505) 955-9454
(505) 216-9067
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA2010-0058
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
25773119
—
NM
Enumeration date
09/21/2010
Last updated
03/26/2026
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