Healthcare Provider Details

I. General information

NPI: 1215472519
Provider Name (Legal Business Name): DYANE LYN CAVAGNARO-IRVINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

216 BRYANT AVE
STATEN ISLAND NY
10306-3104
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-9360
  • Fax:
Mailing address:
  • Phone: 718-351-8287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005387-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: