Provider Demographics
NPI:1467236745
Name:CANNON, CHARLES (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 CRANE CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6832
Mailing Address - Country:US
Mailing Address - Phone:214-564-8293
Mailing Address - Fax:
Practice Address - Street 1:1953 CRANE CREEK BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-6832
Practice Address - Country:US
Practice Address - Phone:214-564-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA24789225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant