Healthcare Provider Details

I. General information

NPI: 1134764574
Provider Name (Legal Business Name): KAILA GAUGHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST 4 SILVERSTEIN
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

3400 SPRUCE ST 4 SILVERSTEIN
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 215-615-4949
  • Fax: 215-662-2244
Mailing address:
  • Phone: 215-615-4949
  • Fax: 215-662-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA064141
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: