Provider Demographics
NPI:1801292412
Name:CANNON, MELISSA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 RESURGENCE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7211
Mailing Address - Country:US
Mailing Address - Phone:706-543-5858
Mailing Address - Fax:
Practice Address - Street 1:1180 RESURGENCE DR STE 100
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7211
Practice Address - Country:US
Practice Address - Phone:706-543-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7337363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant