Provider Demographics
NPI:1316968563
Name:WAYNE CANNON PT AND ASSOCIATES
Entity type:Organization
Organization Name:WAYNE CANNON PT AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:BURLEY
Authorized Official - Last Name:BROWNING
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:336-659-8634
Mailing Address - Street 1:760 HIGHLAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7105
Mailing Address - Country:US
Mailing Address - Phone:336-659-8634
Mailing Address - Fax:336-659-8636
Practice Address - Street 1:760 HIGHLAND OAKS DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7105
Practice Address - Country:US
Practice Address - Phone:336-659-8634
Practice Address - Fax:336-659-8636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC21531OtherMEDCOST
NC07965OtherBCBSNC
NC4136091OtherAETNA