Basic Information
| Provider Information | |||||||||
| NPI: | 1184734451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | TERESE | ||||||||
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| Credential: | MD, MS, CMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 W CENTRAL PARK AVE | ||||||||
| Address2: | GENESIS FAMILY MEDICINE CENTER | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528041844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634214400 | ||||||||
| FaxNumber: | 5634214449 | ||||||||
| Practice Location | |||||||||
| Address1: | 1345 W CENTRAL PARK AVE | ||||||||
| Address2: | GENESIS FAMILY MEDICINE CENTER | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528041844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634214400 | ||||||||
| FaxNumber: | 5634214449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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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 | 207R00000X | 35725 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 35725 | IA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0732552 | 05 | IA | MEDICAID | 26710 | 01 | IA | WELLMARK BCBS | OTHER |