Provider Demographics
NPI:1023463742
Name:MCCAN, ANTONIO L SR
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:L
Last Name:MCCAN
Suffix:SR
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 1:2120 KOKO LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2924
Mailing Address - Country:US
Mailing Address - Phone:443-392-7698
Mailing Address - Fax:
Practice Address - Street 1:2120 KOKO LN
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2924
Practice Address - Country:US
Practice Address - Phone:443-392-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM250067485086172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker