Provider Demographics
NPI:1053194225
Name:CANNON, DANIEL TODD
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:TODD
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 ROCKHOUND DR
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-7185
Mailing Address - Country:US
Mailing Address - Phone:770-820-3815
Mailing Address - Fax:
Practice Address - Street 1:175 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1964
Practice Address - Country:US
Practice Address - Phone:706-253-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant