Provider Demographics
NPI:1386954097
Name:CANNON, ADDY ANTLEY (PA-C)
Entity type:Individual
Prefix:
First Name:ADDY
Middle Name:ANTLEY
Last Name:CANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ADDY
Other - Middle Name:ANTLEY
Other - Last Name:SMOKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:126 DILLON DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1018
Mailing Address - Country:US
Mailing Address - Phone:864-327-1212
Mailing Address - Fax:864-327-1211
Practice Address - Street 1:126 DILLON DRIVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1018
Practice Address - Country:US
Practice Address - Phone:864-327-1212
Practice Address - Fax:864-327-1211
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL1562363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical