Provider Demographics
NPI:1689258675
Name:CANNON, ADRIA (STUDENT, PTA)
Entity Type:Individual
Prefix:
First Name:ADRIA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:STUDENT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25777 GOLD BEACH DR SW
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-8529
Mailing Address - Country:US
Mailing Address - Phone:206-708-3850
Mailing Address - Fax:
Practice Address - Street 1:20110 VASHON HWY SW
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-6026
Practice Address - Country:US
Practice Address - Phone:206-463-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60567605225200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant