Healthcare Provider Details

I. General information

NPI: 1073562773
Provider Name (Legal Business Name): LISA M CANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N RTE 17
PARAMUS NJ
07652-3000
US

IV. Provider business mailing address

2105 FREEMAN WAY
ALLENDALE NJ
07401-1780
US

V. Phone/Fax

Practice location:
  • Phone: 551-218-3790
  • Fax: 201-979-1312
Mailing address:
  • Phone: 201-456-5367
  • Fax: 201-979-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA06901700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA06901700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA69017
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: