Provider Demographics
NPI:1215991484
Name:CANNON, MARK ANDREW (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:CANNON
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:100 EMANCIPATION DR
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:757-728-7052
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:757-728-7052
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101892363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical