Provider Demographics
NPI:1093960775
Name:CANNON CASEY, VANDY LYN (PA-C)
Entity Type:Individual
Prefix:
First Name:VANDY
Middle Name:LYN
Last Name:CANNON CASEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VANDY
Other - Middle Name:LYN
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2430 EMERALD PL STE 201
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5743
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:252-565-8463
Practice Address - Street 1:1001 W WILLIAMS ST STE 103
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3978
Practice Address - Country:US
Practice Address - Phone:919-439-7867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-23
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2760051AMedicare PIN
NC0397730032Medicare NSC