Healthcare Provider Details

I. General information

NPI: 1811394976
Provider Name (Legal Business Name): TANNER CAVANAUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 MCHENRY AVE STE 101
MODESTO CA
95350-1439
US

IV. Provider business mailing address

PO BOX 130
OWYHEE NV
89832
US

V. Phone/Fax

Practice location:
  • Phone: 209-575-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number74381
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number59206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: