Basic Information
| Provider Information | |||||||||
| NPI: | 1629518220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | JEREMIAH | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1503 COBURN AVE | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824013611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039819215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 CHARLES AVE | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824014021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073472449 | ||||||||
| FaxNumber: | 3078645226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2017 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 25938.1600 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.