=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932252756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS GAVIN RPA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 STATE ROUTE 3
-----------------------------------------------------
City | PLATTSBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12901-6562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-566-0672
-----------------------------------------------------
Fax | 518-566-0641
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 483 COOLIDGE HILL RD
-----------------------------------------------------
City | DIAMOND POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12824-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-578-1703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 005798
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------