Provider Demographics
NPI:1790212629
Name:CANNON, PAUL (PA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 W COUGAR BLVD STE 503
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3323
Mailing Address - Country:US
Mailing Address - Phone:801-442-3936
Mailing Address - Fax:
Practice Address - Street 1:395 W COUGAR BLVD STE 503
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3323
Practice Address - Country:US
Practice Address - Phone:801-442-3936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005119363AM0700X
363AM0700X
UT12917809-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical