Healthcare Provider Details

I. General information

NPI: 1902329287
Provider Name (Legal Business Name): JOEL CANNON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3876 HIGHWAY 90
PACE FL
32571
US

IV. Provider business mailing address

3876 HIGHWAY 90
PACE FL
32571-1095
US

V. Phone/Fax

Practice location:
  • Phone: 850-994-6318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number30708
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: