Provider Demographics
NPI:1700855541
Name:CANNON, GREGORY (NP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:NP
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 3109
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-3109
Mailing Address - Country:US
Mailing Address - Phone:252-291-8523
Mailing Address - Fax:252-291-9110
Practice Address - Street 1:511 PALADIN DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7826
Practice Address - Country:US
Practice Address - Phone:252-752-8880
Practice Address - Fax:252-317-2092
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC960004363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC15254OtherBCBSNC
S26185Medicare UPIN
NC15254OtherBCBSNC