Provider Demographics
NPI:1750939799
Name:MISCANNON, ALEXANDER T
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:T
Last Name:MISCANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MAIN ST STE 8
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-1400
Mailing Address - Country:US
Mailing Address - Phone:856-360-5630
Mailing Address - Fax:610-933-3376
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:STE 8
Practice Address - City:RIVERTON
Practice Address - State:NJ
Practice Address - Zip Code:08077-1400
Practice Address - Country:US
Practice Address - Phone:856-360-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01942800225100000X
PAPT028019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist