Provider Demographics
NPI:1508997867
Name:CANNAVA, PETER PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:PAUL
Last Name:CANNAVA
Suffix:
Gender:M
Credentials:PHD
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 2949
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2949
Mailing Address - Country:US
Mailing Address - Phone:907-260-7300
Mailing Address - Fax:907-260-7301
Practice Address - Street 1:230 E MARYDALE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7648
Practice Address - Country:US
Practice Address - Phone:907-260-3691
Practice Address - Fax:907-260-7301
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK516103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKFH177FQMedicaid
AKMH0156Medicaid
AKMH0156Medicaid
AKFH177FQMedicaid
AKK162666Medicare PIN
AKMH0156Medicaid