Provider Demographics
NPI:1275688772
Name:CANNON, CECILIA S (PA)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:S
Last Name:CANNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-758-2602
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:1762 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-2231
Practice Address - Country:US
Practice Address - Phone:864-591-2261
Practice Address - Fax:864-591-2271
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA3618868Medicare PIN