Healthcare Provider Details

I. General information

NPI: 1669380606
Provider Name (Legal Business Name): GAGE PAVELY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 BAGNELL DAM BLVD
LAKE OZARK MO
65049-8658
US

IV. Provider business mailing address

907 JASON RD
JEFFERSON CITY MO
65109-5810
US

V. Phone/Fax

Practice location:
  • Phone: 573-365-2318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2026042244
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: