Provider Demographics
NPI:1184637654
Name:GORDON-CANNING, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GORDON-CANNING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 30TH ST
Mailing Address - Street 2:SUITE411
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-987-8616
Mailing Address - Fax:510-987-8619
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:SUITE411
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-987-8616
Practice Address - Fax:510-987-8619
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17769363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA177690Medicaid
CTS60363Medicare UPIN