Provider Demographics
NPI:1033147962
Name:SNYDER, GAVIN (PA)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:SNYDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 S DECKER AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3946
Mailing Address - Country:US
Mailing Address - Phone:410-491-9769
Mailing Address - Fax:
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:WILSON MEDICAL CENTER
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02769363A00000X
NC0010-00851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKR80I522Medicare ID - Type Unspecified
MDQ14705Medicare UPIN