Provider Demographics
NPI:1457912172
Name:CAVAGNARO, CARLY (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:CAVAGNARO
Suffix:
Gender:F
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 1:185 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-3311
Mailing Address - Country:US
Mailing Address - Phone:201-317-1032
Mailing Address - Fax:
Practice Address - Street 1:185 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-3311
Practice Address - Country:US
Practice Address - Phone:201-317-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164631OtherNCCPA