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NPI Code Detail

MEDICARE: DR. DYLAN JACE CANNON MD

MEDICARE: DR. DYLAN JACE CANNON MD
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
1390200000XStudent in an Organized Health Care Education/Training Program
2207X00000XOrthopaedic Surgery Physician39531OK

General Provider Information

NPI Number : 1770104812
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DYLAN JACE CANNON MD
Provider Business Mailing Address
First Line : 800 STANTON L YOUNG BLVD # 3422
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73104-5018
Country : US
Telephone Number : 405-271-4426
Fax Number :
Provider Business Practice Location Address
First Line : 800 STANTON L YOUNG BLVD # 3422
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73104-5018
Country : US
Telephone Number : 405-271-4426
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/29/2020
Last Update Date : 06/08/2022

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