Provider Demographics
NPI:1073562773
Name:CANNON, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-0158
Mailing Address - Country:US
Mailing Address - Phone:201-512-9494
Mailing Address - Fax:201-512-1995
Practice Address - Street 1:110 WARREN AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1566
Practice Address - Country:US
Practice Address - Phone:201-251-2525
Practice Address - Fax:201-251-8488
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69017174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G49906Medicare UPIN
026226Medicare ID - Type Unspecified