Provider Demographics
NPI:1235215435
Name:CAVANAGH, ERIC J (PAC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:CAVANAGH
Suffix:
Gender:M
Credentials:PAC
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 437
Mailing Address - Street 2:1
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78292-0437
Mailing Address - Country:US
Mailing Address - Phone:210-558-6288
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:1200 N BEDELL AVE
Practice Address - Street 2:1
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4491
Practice Address - Country:US
Practice Address - Phone:830-774-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2414363A00000X
TX09270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ870594Medicaid