Healthcare Provider Details

I. General information

NPI: 1265943252
Provider Name (Legal Business Name): GAVIN FERGUSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E CEDAR AVE STE 2B3B4E12
FLAGSTAFF AZ
86004-1600
US

IV. Provider business mailing address

3331 S GILLENWATER DR
FLAGSTAFF AZ
86005-8983
US

V. Phone/Fax

Practice location:
  • Phone: 928-714-0010
  • Fax:
Mailing address:
  • Phone: 928-600-2185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6948
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6948
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: