Provider Demographics
NPI:1912791484
Name:CANON, NATHANIEL (PTA)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:CANON
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 DAVIS RD. ST. M
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 DAVIS RD. ST. M
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573
Practice Address - Country:US
Practice Address - Phone:281-338-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2170465261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy