Provider Demographics
NPI:1457673972
Name:CANONICA, CAROLYN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:CANONICA
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1804 EMBARCADERO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-3318
Mailing Address - Country:US
Mailing Address - Phone:650-497-0363
Mailing Address - Fax:650-498-5840
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:650-498-5840
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2017-05-16
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Provider Licenses
StateLicense IDTaxonomies
CA54326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant