Provider Demographics
NPI:1093166266
Name:GAVAGA, ALEXA MARY CLARE
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:MARY CLARE
Last Name:GAVAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 S MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1282
Mailing Address - Country:US
Mailing Address - Phone:201-515-7883
Mailing Address - Fax:
Practice Address - Street 1:835 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1282
Practice Address - Country:US
Practice Address - Phone:920-855-2823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI70162-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program