Provider Demographics
NPI:1801081393
Name:CANNON, BRYANT
Entity type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:
Last Name:CANNON
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 1:544 E OGDEN AVE
Mailing Address - Street 2:700-265
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2698
Mailing Address - Country:US
Mailing Address - Phone:414-745-1737
Mailing Address - Fax:
Practice Address - Street 1:544 E OGDEN AVE
Practice Address - Street 2:700-265
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2698
Practice Address - Country:US
Practice Address - Phone:414-745-1737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-08
Last Update Date:2007-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN188908246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4147451737Medicare UPIN