Healthcare Provider Details

I. General information

NPI: 1396610937
Provider Name (Legal Business Name): BRANDON GAVIOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ RM 314
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-963-6770
  • Fax:
Mailing address:
  • Phone: 848-288-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15352600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15352600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: