Provider Demographics
NPI:1164495743
Name:MCCAFFERTY, KEVIN JOHN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOHN
Last Name:MCCAFFERTY
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 1:102 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:VENTNOR CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08406-3030
Mailing Address - Country:US
Mailing Address - Phone:609-822-5745
Mailing Address - Fax:609-822-5749
Practice Address - Street 1:3205 FIRE RD
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5884
Practice Address - Country:US
Practice Address - Phone:609-407-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR04704300367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
030373Medicare ID - Type Unspecified