Provider Demographics
NPI:1366059206
Name:CANNON, JAMES (PTA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CARROUSEL LN
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3446
Mailing Address - Country:US
Mailing Address - Phone:609-664-1663
Mailing Address - Fax:
Practice Address - Street 1:4609 NOTTINGHAM WAY
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-3819
Practice Address - Country:US
Practice Address - Phone:609-436-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00358400225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant