Provider Demographics
NPI:1053805671
Name:GANZ, JEREMY (PA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GANZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Mailing Address - Street 2:224 W D. L. INGRAM AVENUE, BLDG. 1408
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Practice Address - Street 2:224 W D. L. INGRAM AVENUE, BLDG. 1408
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:314-226-8463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2024-01-22
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider