Provider Demographics
NPI:1104558527
Name:CANNON, ANDY ALLEN (APRN)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:ALLEN
Last Name:CANNON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S WHEELING AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5656
Mailing Address - Country:US
Mailing Address - Phone:918-748-7854
Mailing Address - Fax:918-403-6335
Practice Address - Street 1:2000 S WHEELING AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5656
Practice Address - Country:US
Practice Address - Phone:918-748-7854
Practice Address - Fax:918-403-6335
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK208609363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care