Provider Demographics
NPI:1043288541
Name:CAVALIER, GLEN MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:MICHAEL
Last Name:CAVALIER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:STE 230A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3483
Mailing Address - Country:US
Mailing Address - Phone:228-831-0204
Mailing Address - Fax:228-831-1868
Practice Address - Street 1:15200 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3085
Practice Address - Country:US
Practice Address - Phone:228-575-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162301A367500000X
MSR875676367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered