Provider Demographics
NPI:1568116770
Name:CONCANNON, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:CONCANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11225 CYPRESS TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5027
Mailing Address - Country:US
Mailing Address - Phone:407-797-5058
Mailing Address - Fax:
Practice Address - Street 1:298 MICHIGAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3104
Practice Address - Country:US
Practice Address - Phone:321-215-6899
Practice Address - Fax:321-215-6789
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant