Provider Demographics
NPI:1639802945
Name:CAVANAGH, CODY MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:MICHAEL
Last Name:CAVANAGH
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 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-7932
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-7932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA100826363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant