Healthcare Provider Details

I. General information

NPI: 1033735618
Provider Name (Legal Business Name): GAVIN GUARD DMS, PA-C, MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2939 W EXCURSION LN
MERIDIAN ID
83642-5308
US

IV. Provider business mailing address

2939 W EXCURSION LN
MERIDIAN ID
83642-5308
US

V. Phone/Fax

Practice location:
  • Phone: 208-385-7711
  • Fax: 208-385-0346
Mailing address:
  • Phone: 208-385-7711
  • Fax: 208-385-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61076381
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: