Provider Demographics
NPI:1275288821
Name:CANNON, TYLER ROSS (DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ROSS
Last Name:CANNON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 W SAHUARO DR APT 25-204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5803
Mailing Address - Country:US
Mailing Address - Phone:208-705-2677
Mailing Address - Fax:
Practice Address - Street 1:1818 E SKY HARBOR CIR N STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-3410
Practice Address - Country:US
Practice Address - Phone:602-244-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist