Basic Information
| Provider Information | |||||||||
| NPI: | 1801265095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | BRADY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 804408 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641804408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136474100 | ||||||||
| FaxNumber: | 9136474120 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167817200 | ||||||||
| FaxNumber: | 8167927196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2015 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2015033276 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 57687015 | 01 | MO | BCBS KC | OTHER | 910026513 | 05 | MO | MEDICAID | P02049871 | 01 | MO | RAILROAD | OTHER |