Provider Demographics
NPI:1235287509
Name:KAVANAUGH, THOMAS J (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KAVANAUGH
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 1:8901 W. LINCOLN AVE
Mailing Address - Street 2:AURORA WEST ALLIS MEDICAL CENTER
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227
Mailing Address - Country:US
Mailing Address - Phone:414-328-6000
Mailing Address - Fax:414-328-8536
Practice Address - Street 1:8901 W. LINCOLN AVE
Practice Address - Street 2:AURORA WEST ALLIS MEDICAL CENTER
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227
Practice Address - Country:US
Practice Address - Phone:414-328-6000
Practice Address - Fax:414-328-8536
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1154-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKAVANTHOOtherMERCYCARE
WI43284100Medicaid
WI430054293Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI0031Medicare ID - Type UnspecifiedMEDICARE PRO FEE SEQ. #
WI43284100Medicaid
WIKAVANTHOOtherMERCYCARE