Healthcare Provider Details

I. General information

NPI: 1235380601
Provider Name (Legal Business Name): KRYSTAL B CANAVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 DODGE ST
BEVERLY MA
01915-1711
US

IV. Provider business mailing address

50 DODGE ST
BEVERLY MA
01915-1711
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-2171
  • Fax:
Mailing address:
  • Phone: 978-922-2171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2614
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: