Healthcare Provider Details

I. General information

NPI: 1215146311
Provider Name (Legal Business Name): CATHERINE LYNN GAVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/07/2023
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48681 HAYES RD SUITE 200
SHELBY TOWNSHIP MI
48315-4403
US

IV. Provider business mailing address

54220 MAPLE CREEK CT
SHELBY TOWNSHIP MI
48316-6013
US

V. Phone/Fax

Practice location:
  • Phone: 586-799-1212
  • Fax: 586-799-1210
Mailing address:
  • Phone: 586-697-6152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002698
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: