Provider Demographics
NPI:1215071725
Name:CANNON, KATIE MARRIA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:MARRIA
Last Name:CANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:MARRIA
Other - Last Name:SINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:210 W SAINT GEORGES AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-3900
Mailing Address - Country:US
Mailing Address - Phone:908-486-1111
Mailing Address - Fax:908-486-2723
Practice Address - Street 1:210 W SAINT GEORGES AVE FL 2
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-3900
Practice Address - Country:US
Practice Address - Phone:908-486-1111
Practice Address - Fax:908-486-2723
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NJ25MP00279100363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical