Provider Demographics
NPI:1073370649
Name:CANNON, ARTHUR RONALD JR
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:RONALD
Last Name:CANNON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 BINBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1004
Mailing Address - Country:US
Mailing Address - Phone:734-730-1766
Mailing Address - Fax:
Practice Address - Street 1:1480 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1739
Practice Address - Country:US
Practice Address - Phone:248-651-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002235225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant