Healthcare Provider Details

I. General information

NPI: 1245637073
Provider Name (Legal Business Name): RICHARD CANNON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

3510 N CAUSEWAY BLVD STE 404
METAIRIE LA
70002-3531
US

V. Phone/Fax

Practice location:
  • Phone: 504-779-5515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP08107
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: