Basic Information
| Provider Information | |||||||||
| NPI: | 1174875991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | DEANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1522 E A ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072346161 | ||||||||
| FaxNumber: | 3072347032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 E A ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072346161 | ||||||||
| FaxNumber: | 3072347032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.