Individual
BRYAN JAMES CANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
16555 MANCHESTER RD, SUITE 100, WILDWOOD, MO 63040-1220
(636) 458-0646
Mailing address
16555 MANCHESTER RD, SUITE 100, WILDWOOD, MO 63040-1220
(636) 458-0646
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2016016732
MO
207Q00000X
Family Medicine Physician
6038
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1265662068
—
MO
Enumeration date
07/15/2009
Last updated
02/08/2017
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