MEDICARE: MARIAELENA GAVILANES PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	PA60874	CA

General Provider Information

NPI Number	:	1407506942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAELENA GAVILANES PA-C

Provider Business Mailing Address
First Line	:	4667 MACARTHUR BLVD STE 220
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-1816
Country	:	US
Telephone Number	:	949-867-0091
Fax Number	:

Provider Business Practice Location Address
First Line	:	32406 COAST HWY
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-6783
Country	:	US
Telephone Number	:	949-499-4147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2022
Last Update Date	:	01/25/2025

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