Provider Demographics
NPI:1154823441
Name:CANNON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CANNON
Suffix:
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 1:301 NW F ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2051
Mailing Address - Country:US
Mailing Address - Phone:541-474-5177
Mailing Address - Fax:541-474-5181
Practice Address - Street 1:301 NW F ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2051
Practice Address - Country:US
Practice Address - Phone:541-474-5177
Practice Address - Fax:541-474-5181
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator