Provider Demographics
NPI:1295803799
Name:CANNON, RANDY T (PT)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:T
Last Name:CANNON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6167
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-6167
Mailing Address - Country:US
Mailing Address - Phone:865-977-8007
Mailing Address - Fax:865-977-4072
Practice Address - Street 1:785 US HWY 321 N
Practice Address - Street 2:STE 20
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771
Practice Address - Country:US
Practice Address - Phone:865-986-6611
Practice Address - Fax:865-988-6904
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000001415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist