Provider Demographics
NPI:1669524526
Name:CAVANNA, CHRISTOPHER ALAN (PAC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ALAN
Last Name:CAVANNA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:MR
Other - First Name:CHRIS
Other - Middle Name:ALAN
Other - Last Name:CAVANNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:214 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6546
Mailing Address - Country:US
Mailing Address - Phone:860-836-9168
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-545-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant