Provider Demographics
NPI:1144402009
Name:VIRGINIA R CANNON MD PLLC
Entity Type:Organization
Organization Name:VIRGINIA R CANNON MD PLLC
Other - Org Name:WEST OLYMPIA BONE DENSITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:360-352-3232
Mailing Address - Street 1:406 YAUGER WAY SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8151
Mailing Address - Country:US
Mailing Address - Phone:360-352-3232
Mailing Address - Fax:360-352-2942
Practice Address - Street 1:406 YAUGER WAY SW
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8151
Practice Address - Country:US
Practice Address - Phone:360-352-3232
Practice Address - Fax:360-352-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA117480Medicaid
WAGAB34573Medicare PIN
WA117480Medicaid