Provider Demographics
NPI:1578759064
Name:CAVANAGH, GLENN JAMES (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:JAMES
Last Name:CAVANAGH
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 1:11 VALLEY VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:NY
Mailing Address - Zip Code:10516
Mailing Address - Country:US
Mailing Address - Phone:914-924-3867
Mailing Address - Fax:
Practice Address - Street 1:302 E 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4772
Practice Address - Country:US
Practice Address - Phone:914-924-3867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037894367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered