Provider Demographics
NPI:1134683394
Name:VINCENT, GAVIN BLAKE (PA-C)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:BLAKE
Last Name:VINCENT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PARKVIEW DR APT 102
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-4570
Mailing Address - Country:US
Mailing Address - Phone:304-991-2898
Mailing Address - Fax:
Practice Address - Street 1:800 GRAND CENTRAL MALL STE 3
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4100
Practice Address - Country:US
Practice Address - Phone:304-865-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WV2709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer