Provider Demographics
NPI:1255616918
Name:CANNER, ABBY (PA)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:CANNER
Suffix:
Gender:F
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:PO BOX 415257
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5257
Mailing Address - Country:US
Mailing Address - Phone:781-280-1500
Mailing Address - Fax:
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3225
Practice Address - Country:US
Practice Address - Phone:781-979-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant