MEDICARE: PAUL KENNETH GAVINS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	2328-023	WI
2	363AS0400X	Surgical Physician Assistant	2328-023	WI
3	363A00000X	Physician Assistant	2328-023	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952308272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL KENNETH GAVINS PA-C

Provider Business Mailing Address
First Line	:	700 S PARK ST
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53715-1830
Country	:	US
Telephone Number	:	608-260-2900
Fax Number	:	608-260-3447

Provider Business Practice Location Address
First Line	:	700 S PARK ST
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53715-1830
Country	:	US
Telephone Number	:	608-260-2900
Fax Number	:	608-260-3447

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	11/24/2020

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