Provider Demographics
NPI:1346331154
Name:KAVANAGH, FREDERICK PATRICK (RPA-C)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:PATRICK
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1715
Mailing Address - Country:US
Mailing Address - Phone:631-738-7417
Mailing Address - Fax:
Practice Address - Street 1:1869 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4625
Practice Address - Country:US
Practice Address - Phone:631-853-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006209-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS89584Medicare UPIN
NY0F4391Medicare ID - Type Unspecified