Provider Demographics
NPI:1649271313
Name:CAVENAGH, JOHN M (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:CAVENAGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4190 CITY LINE AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1626
Mailing Address - Country:US
Mailing Address - Phone:215-871-6380
Mailing Address - Fax:215-871-6381
Practice Address - Street 1:4190 CITY LINE AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:215-871-6380
Practice Address - Fax:215-871-6381
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOA000378L363A00000X
PAMA000252L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P97138Medicare UPIN
PA072882E7HMedicare PIN