Active NPI
Colleen M Canavan, PA
- Physician Assistant
- Jerseyville, IL
National Provider Identifier
1205090644
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 085000651
- Practice address
- 390 Maple Summit Rd
Jerseyville, IL 62052-2000 - Phone
- (618) 498-2101
- Fax
- (618) 498-8153
- NPI assigned
- Jul 15, 2008
- Last updated
- Sep 21, 2016
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 085000651 | IL | Primary |
Addresses
Primary practice location
390 Maple Summit Rd
Jerseyville, IL 62052-2000
Mailing address
390 Maple Summit Rd
Jerseyville, IL 62052-2000
Phone (618) 498-2101
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1216080000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1474416000000",
"number": "1205090644",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "390 MAPLE SUMMIT RD",
"city": "JERSEYVILLE",
"state": "IL",
"postal_code": "620522000",
"telephone_number": "618-498-2101",
"fax_number": "618-498-8153"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "390 MAPLE SUMMIT RD",
"city": "JERSEYVILLE",
"state": "IL",
"postal_code": "620522000",
"telephone_number": "618-498-2101",
"fax_number": "618-498-8153"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CANAVAN",
"first_name": "COLLEEN",
"middle_name": "M",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2008-07-15",
"last_updated": "2016-09-21",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "IL",
"license": "085000651",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jerseyville, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.