Healthcare Provider Details

I. General information

NPI: 1376559955
Provider Name (Legal Business Name): MICHAEL F CAVANAUGH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 SMITH AVE N STE 100
SAINT PAUL MN
55102-2518
US

IV. Provider business mailing address

5316 187TH ST W
FARMINGTON MN
55024-8952
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-0616
  • Fax:
Mailing address:
  • Phone: 651-460-6490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR 144407-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: