Healthcare Provider Details

I. General information

NPI: 1043210347
Provider Name (Legal Business Name): HONOR CANON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 S 1ST ST
AUSTIN TX
78704-7048
US

IV. Provider business mailing address

PO BOX 26726
AUSTIN TX
78755-0726
US

V. Phone/Fax

Practice location:
  • Phone: 512-443-1311
  • Fax: 512-448-8250
Mailing address:
  • Phone: 512-407-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM6065
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: