Provider Demographics
NPI:1902450083
Name:CANNON, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
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 1:687 BEAR RIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5605
Mailing Address - Country:US
Mailing Address - Phone:425-495-4082
Mailing Address - Fax:
Practice Address - Street 1:687 BEAR RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5605
Practice Address - Country:US
Practice Address - Phone:425-495-4082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer