Provider Demographics
NPI:1558432922
Name:CAVANAUGH, TIMOTHY S (PAC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:T
Other - Middle Name:SHAWN
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:1288 ROUTE 73 SOUTH
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054
Mailing Address - Country:US
Mailing Address - Phone:856-273-8900
Mailing Address - Fax:856-802-9772
Practice Address - Street 1:1288 ROUTE 73 SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:MT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054
Practice Address - Country:US
Practice Address - Phone:856-273-8900
Practice Address - Fax:856-802-9772
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00098900363A00000X
PAMA050758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant