Provider Demographics
NPI:1770529406
Name:CAVANAGH, MICHAEL K (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
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 1:1802 YAKIMA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5303
Mailing Address - Country:US
Mailing Address - Phone:253-272-7777
Mailing Address - Fax:
Practice Address - Street 1:1802 YAKIMA AVE STE 102
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5303
Practice Address - Country:US
Practice Address - Phone:253-272-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003792363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045595Medicaid
WAP00220038OtherMEDICARE RAILROAD
WA8926049OtherCRIME VICTIMS
WA0127008OtherSTATE L&I
WA8403339Medicaid
WAP00220038OtherMEDICARE RAILROAD
WA8403339Medicaid