Healthcare Provider Details

I. General information

NPI: 1922474618
Provider Name (Legal Business Name): DEVYNE GASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1196 SWIFT CREEK DR
NEW AUBURN WI
54757-9902
US

IV. Provider business mailing address

1196 SWIFT CREEK DR
NEW AUBURN WI
54757-9902
US

V. Phone/Fax

Practice location:
  • Phone: 715-202-0581
  • Fax:
Mailing address:
  • Phone: 715-202-0581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number19697630
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: