Provider Demographics
NPI:1194834457
Name:CANON, GINA A (PA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:A
Last Name:CANON
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 1:2777 MILE HIGH STADIUM CIR
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5222
Mailing Address - Country:US
Mailing Address - Phone:303-825-8822
Mailing Address - Fax:303-825-4022
Practice Address - Street 1:2777 MILE HIGH STADIUM CIR
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5222
Practice Address - Country:US
Practice Address - Phone:303-825-8822
Practice Address - Fax:303-825-4022
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84158239Medicaid
CO84158239Medicaid