Provider Demographics
NPI:1780954511
Name:CANNON, BLAIR BOEVING (CRNA)
Entity type:Individual
Prefix:MRS
First Name:BLAIR
Middle Name:BOEVING
Last Name:CANNON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 BARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-1611
Mailing Address - Country:US
Mailing Address - Phone:901-359-2512
Mailing Address - Fax:
Practice Address - Street 1:1755 KIRBY PKWY
Practice Address - Street 2:STE. 330
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-8300
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:901-726-4827
Is Sole Proprietor?:No
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000158063367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered