Healthcare Provider Details

I. General information

NPI: 1841279940
Provider Name (Legal Business Name): JASON ANDREW CANNELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 48TH ST SUITE 200
BOULDER CO
80301-2711
US

IV. Provider business mailing address

5450 WESTERN AVE
BOULDER CO
80301-2709
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-7450
  • Fax: 303-494-5265
Mailing address:
  • Phone: 303-415-7450
  • Fax: 303-494-5265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOS-1087
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0050333
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: