Provider Demographics
NPI:1003624545
Name:CAVIGLI, IAN (PA-C)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:CAVIGLI
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 1:1401 N 10TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1486
Mailing Address - Country:US
Mailing Address - Phone:503-769-6386
Mailing Address - Fax:
Practice Address - Street 1:1401 N 10TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1486
Practice Address - Country:US
Practice Address - Phone:503-769-6386
Practice Address - Fax:503-769-5647
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA224199363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant