Provider Demographics
NPI:1730744608
Name:CAVANAUGH, DANIELLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:TETREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:
Practice Address - Street 1:100 BROAD ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4349
Practice Address - Country:US
Practice Address - Phone:518-792-2223
Practice Address - Fax:518-792-8231
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05930130Medicaid