Healthcare Provider Details

I. General information

NPI: 1952308272
Provider Name (Legal Business Name): PAUL KENNETH GAVINS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S PARK ST
MADISON WI
53715-1830
US

IV. Provider business mailing address

700 S PARK ST
MADISON WI
53715-1830
US

V. Phone/Fax

Practice location:
  • Phone: 608-260-2900
  • Fax: 608-260-3447
Mailing address:
  • Phone: 608-260-2900
  • Fax: 608-260-3447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2328-023
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2328-023
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2328-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: