Provider Demographics
NPI:1235380601
Name:CANAVAN, BARRY F (PA-C)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:F
Last Name:CANAVAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5615
Mailing Address - Country:US
Mailing Address - Phone:617-506-4471
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLAND ST
Practice Address - Street 2:SUITE 222
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3881
Practice Address - Country:US
Practice Address - Phone:617-696-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2009-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA2614363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical