Provider Demographics
NPI:1992102347
Name:CANNON, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CANNON
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 1:1700 S AMPHLETT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2717
Mailing Address - Country:US
Mailing Address - Phone:650-685-6558
Mailing Address - Fax:650-240-8669
Practice Address - Street 1:1700 S AMPHLETT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2717
Practice Address - Country:US
Practice Address - Phone:650-685-6558
Practice Address - Fax:650-240-8669
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47-2097352251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health