Provider Demographics
NPI:1952605552
Name:CANNON, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
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 1:4611 E PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-1258
Mailing Address - Country:US
Mailing Address - Phone:602-315-0211
Mailing Address - Fax:602-840-1290
Practice Address - Street 1:4611 E PALO VERDE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-1258
Practice Address - Country:US
Practice Address - Phone:602-315-0211
Practice Address - Fax:602-840-1290
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor