Provider Demographics
NPI:1578171492
Name:CANAVAN, CARLY ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELLEN
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 LIPTON ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1814
Mailing Address - Country:US
Mailing Address - Phone:845-389-6644
Mailing Address - Fax:
Practice Address - Street 1:1499 NEW SCOTLAND RD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9209
Practice Address - Country:US
Practice Address - Phone:518-320-7517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant