Provider Demographics
NPI:1801286976
Name:CANAAN, ROBERT B
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:B
Last Name:CANAAN
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 1:1900 S DOUGLAS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3625
Mailing Address - Country:US
Mailing Address - Phone:801-347-1553
Mailing Address - Fax:
Practice Address - Street 1:1900 S DOUGLAS ST APT 2
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3625
Practice Address - Country:US
Practice Address - Phone:801-347-1553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2014-PCA-UT000630251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT901034250002Medicaid