Provider Demographics
NPI:1871548115
Name:CAVANAUGH, CHRISTINE D (PA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:D
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1141 N OLIVE AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-3365
Practice Address - Country:US
Practice Address - Phone:209-667-2749
Practice Address - Fax:209-668-5396
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN544279163W00000X
CA1050160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP12234Medicaid
CAZZZ05855ZMedicare PIN
CAP21744Medicare UPIN