Provider Demographics
NPI:1932642444
Name:CANON, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CANON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4034
Mailing Address - Fax:970-490-4347
Practice Address - Street 1:1400 E BOULDER ST STE 2508
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-365-6999
Practice Address - Fax:719-365-2837
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008194367H00000X
COANT.0000107367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant