Provider Demographics
NPI:1538161278
Name:CAVANAUGH, MICHAEL W (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:CAVANAUGH
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 1:500 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1842
Mailing Address - Country:US
Mailing Address - Phone:715-344-0701
Mailing Address - Fax:715-344-4494
Practice Address - Street 1:500 VINCENT ST
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1842
Practice Address - Country:US
Practice Address - Phone:715-344-0701
Practice Address - Fax:715-344-4494
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1864-023208600000X
WI1864-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42870400Medicaid
WI42870400Medicaid
WI045895Medicare UPIN