Healthcare Provider Details

I. General information

NPI: 1790715183
Provider Name (Legal Business Name): JOHN CAGNOLA III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N SPRUCE ST 11C-C
COLORADO SPRINGS CO
80905-1436
US

IV. Provider business mailing address

25 N SPRUCE ST 11C-C
COLORADO SPRINGS CO
80905-1436
US

V. Phone/Fax

Practice location:
  • Phone: 719-327-5697
  • Fax: 719-633-8741
Mailing address:
  • Phone: 719-327-5697
  • Fax: 719-633-8741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3214
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: