Provider Demographics
NPI:1508622598
Name:CANNON, KEITH
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9864 OLDHAM DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-0664
Mailing Address - Country:US
Mailing Address - Phone:262-672-8641
Mailing Address - Fax:
Practice Address - Street 1:825 OHIO ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-2205
Practice Address - Country:US
Practice Address - Phone:262-672-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)