Healthcare Provider Details

I. General information

NPI: 1194148130
Provider Name (Legal Business Name): GAVIN W NOWELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

PO BOX 16076
JACKSON MS
39236-6076
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1700
  • Fax:
Mailing address:
  • Phone: 601-936-6001
  • Fax: 601-936-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: