Provider Demographics
NPI:1609839125
Name:CANNON, MICHELLE R (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:CANNON
Suffix:
Gender:F
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 1:650 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:P.O. BOX 1845
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4353
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:
Practice Address - Street 1:619 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3437
Practice Address - Country:US
Practice Address - Phone:704-878-9309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102143363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752721Medicare ID - Type Unspecified
NCS97750Medicare UPIN