Provider Demographics
NPI:1851717615
Name:CAVANAUGH, KRISTEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:L
Other - Last Name:MCMULLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4300 LONDONDERRY RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-5317
Mailing Address - Country:US
Mailing Address - Phone:717-988-0000
Mailing Address - Fax:717-782-5716
Practice Address - Street 1:4300 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5317
Practice Address - Country:US
Practice Address - Phone:717-988-0000
Practice Address - Fax:717-782-5716
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103190636Medicaid