1215146311 NPI number — MRS. CATHERINE LYNN GAVAN PA-C

Table of content: MRS. CATHERINE LYNN GAVAN PA-C (NPI 1215146311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215146311 NPI number — MRS. CATHERINE LYNN GAVAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAVAN
Provider First Name:
CATHERINE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215146311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54220 MAPLE CREEK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48316-6013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-697-6152
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48681 HAYES RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SHELBY TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48315-4403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-799-1212
Provider Business Practice Location Address Fax Number:
586-799-1210
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601002698 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1755014270 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CG002698 . This is a "MICHIGAN STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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