Provider Demographics
NPI:1790737294
Name:CANNON, STEPHEN JEROME (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JEROME
Last Name:CANNON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2341
Mailing Address - Country:US
Mailing Address - Phone:850-477-8109
Mailing Address - Fax:850-478-2412
Practice Address - Street 1:4810 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2341
Practice Address - Country:US
Practice Address - Phone:850-474-8988
Practice Address - Fax:850-476-5312
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28237950A367500000X
TXAP115468367500000X
FLARNP9205700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001096178OtherANTHEM PROVIDER NUMBER
P00166590OtherPALMETTO GBA-RR MEDICARE
AL009982295Medicaid
FLG1321OtherBCBS
IN300004501Medicaid
AL59169960OtherBCBS
AL59169961OtherBCBS
IN000001096178OtherANTHEM PROVIDER NUMBER
IN300004501Medicaid
FLG1321OtherBCBS
FLG1321AMedicare ID - Type Unspecified