Provider Demographics
NPI:1588390033
Name:CANNON, GARRETT (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 LUTHER ST W UNIT 203
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:187 CORRINGTON DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:OR
Practice Address - Zip Code:77840
Practice Address - Country:US
Practice Address - Phone:541-390-5098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT91412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer