Provider Demographics
NPI:1700320272
Name:CANNADY, CAMERON (PTA)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:CANNADY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-2508
Mailing Address - Country:US
Mailing Address - Phone:575-461-2200
Mailing Address - Fax:
Practice Address - Street 1:1302 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2508
Practice Address - Country:US
Practice Address - Phone:575-461-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1289225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant