Provider Demographics
NPI:1619979341
Name:CANAVAN, MARTIN (PT)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:CANAVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:4700 ONONDAGA BLVD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3316
Practice Address - Country:US
Practice Address - Phone:315-475-7121
Practice Address - Fax:315-475-7144
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461672Medicaid
NYRA0066Medicare PIN
NYQ00591Medicare UPIN
NYP00220632Medicare PIN