MEDICARE: MR. CALEB JOHN CANNELLA CAA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367H00000X	Anesthesiologist Assistant	AA741	FL

General Provider Information

NPI Number	:	1346960929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CALEB JOHN CANNELLA CAA

Provider Business Mailing Address
First Line	:	6451 PERSHING ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-2036
Country	:	US
Telephone Number	:	850-597-0753
Fax Number	:

Provider Business Practice Location Address
First Line	:	1525 W CYPRESS CREEK RD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-1831
Country	:	US
Telephone Number	:	800-437-2672
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2022
Last Update Date	:	09/01/2022

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