Provider Demographics
NPI:1689633414
Name:CAVANAUGH, BRUCE ALAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALAN
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9987 VILLAGE GREEN DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1155
Mailing Address - Country:US
Mailing Address - Phone:443-570-2782
Mailing Address - Fax:443-570-2782
Practice Address - Street 1:9987 VILLAGE GREEN DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:MD
Practice Address - Zip Code:21163-1155
Practice Address - Country:US
Practice Address - Phone:443-570-2782
Practice Address - Fax:443-570-2782
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC002022363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP09559Medicare PIN
MDKL19P094Medicare PIN
MDKL09P096Medicare PIN
MDKL33P095Medicare PIN