Provider Demographics
NPI:1699819318
Name:CANNON, DAVID WAYNE (PT, ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:CANNON
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 HIGHLAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7105
Mailing Address - Country:US
Mailing Address - Phone:336-659-8634
Mailing Address - Fax:
Practice Address - Street 1:760 HIGHLAND OAKS DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7105
Practice Address - Country:US
Practice Address - Phone:336-659-8634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0779JOtherBCBS NC