Healthcare Provider Details

I. General information

NPI: 1205779428
Provider Name (Legal Business Name): GAVIN PAUL MARCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S SUMMIT AVE
SIOUX FALLS SD
57197-0001
US

IV. Provider business mailing address

5309 W BIRNHAMWOOD DR
SIOUX FALLS SD
57106-0656
US

V. Phone/Fax

Practice location:
  • Phone: 605-274-0770
  • Fax:
Mailing address:
  • Phone: 605-681-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: