MEDICARE: DOMINIC MICHAEL CANNELLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	49494	MN

General Provider Information

NPI Number	:	1336191477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC MICHAEL CANNELLA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 6210
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87499-6210
Country	:	US
Telephone Number	:	505-609-2258
Fax Number	:	505-609-2259

Provider Business Practice Location Address
First Line	:	407 S SCHWARTZ AVE STE 101
Second Line	:
City	:	FARMINGTON
State	:	NM
Zip	:	87401-5925
Country	:	US
Telephone Number	:	505-609-6595
Fax Number	:	505-609-6579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	02/24/2020

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