Provider Demographics
NPI:1417432501
Name:CANNON, TY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TY
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N 1100 E UNIT 50
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-2883
Mailing Address - Country:US
Mailing Address - Phone:435-231-2961
Mailing Address - Fax:
Practice Address - Street 1:616 S RIVER RD STE 200
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2105
Practice Address - Country:US
Practice Address - Phone:435-628-8944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10974132-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant