1104222793 NPI number — RYAN CAVANAUGH LADUKE PA-C

Table of content: RYAN CAVANAUGH LADUKE PA-C (NPI 1104222793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104222793 NPI number — RYAN CAVANAUGH LADUKE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADUKE
Provider First Name:
RYAN
Provider Middle Name:
CAVANAUGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104222793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 ELMWOOD AVE BOX 655A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14642-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-275-2100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14642-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-275-2100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  PA031095 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA031095 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 23917 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 023917 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023917 . This is a "THE UNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: CA1400053 . This is a "CONTROLLED SUBSTANCE LICESNE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: PA031095 . This is a "PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".