Provider Demographics
NPI:1952066904
Name:CANNON, VICTORIA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ELIZABETH
Last Name:CANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ACORN CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-3111
Mailing Address - Country:US
Mailing Address - Phone:864-451-2745
Mailing Address - Fax:
Practice Address - Street 1:250 PARKBROOKE PL STE 300
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6401
Practice Address - Country:US
Practice Address - Phone:770-442-1911
Practice Address - Fax:770-928-2601
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCMPA.5090PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program