Basic Information
| Provider Information | |||||||||
| NPI: | 1952066904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 ACORN CT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296093111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644512745 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 PARKBROOKE PL STE 300 | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301896401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704421911 | ||||||||
| FaxNumber: | 7709282601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2021 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 10788 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.