Provider Demographics
NPI:1871563924
Name:CANNATA, ALBERT JOHN (PA)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:JOHN
Last Name:CANNATA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9940
Mailing Address - Fax:316-689-9115
Practice Address - Street 1:1947 FOUNDERS' CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-613-4640
Practice Address - Fax:316-613-4739
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100340660AMedicaid
KSR32008Medicare UPIN
KS100340660AMedicaid