Provider Demographics
NPI:1144522459
Name:CANNON, MICHELE M (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:M
Other - Last Name:BESSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1530 S UNION AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1954
Mailing Address - Country:US
Mailing Address - Phone:253-759-3333
Mailing Address - Fax:253-759-1415
Practice Address - Street 1:1530 S UNION AVE STE 1
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1954
Practice Address - Country:US
Practice Address - Phone:253-759-3333
Practice Address - Fax:253-759-1415
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA202849Medicaid