Provider Demographics
NPI:1528020435
Name:CAVANAUGH, THOMAS TIMOTHY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:TIMOTHY
Last Name:CAVANAUGH
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 1:8540 DUNE LAKE RD SE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-8228
Mailing Address - Country:US
Mailing Address - Phone:509-766-9043
Mailing Address - Fax:
Practice Address - Street 1:8540 DUNE LAKE RD SE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-8228
Practice Address - Country:US
Practice Address - Phone:509-766-9043
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9605643Medicaid