Individual
PATRICK RUSSELL GANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1 E CLARK BASS BLVD, SUITE 210, MCALESTER, OK 74501-4209
(918) 421-6987
(918) 421-6698
Mailing address
1245 S UTICA AVE, FL 2, TULSA, OK 74104-4214
(918) 579-2300
(918) 579-2309
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
20652
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0166707
UMWA
OK
05
—
1000176970A
—
OK
01
—
1324230001
PALMETTO DME
OK
01
—
731310891006
UNICARE
OK
01
—
731310891028
TRICARE SOUTH
OK
01
—
74502A024
CHAMPUS
OK
01
—
G67583
STERLING OPTION 1
OK
Enumeration date
04/06/2006
Last updated
01/29/2018
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