Provider Demographics
NPI:1811394976
Name:CAVANAUGH, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:OWYHEE
Mailing Address - State:NV
Mailing Address - Zip Code:89832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 MCHENRY AVE STE 101
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1439
Practice Address - Country:US
Practice Address - Phone:209-575-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV74381146N00000X
CA59206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV74381OtherEMT LICENSCE