Provider Demographics
NPI:1184195083
Name:GAVIGAN, MICHAEL SCOTT (APRN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:GAVIGAN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3111
Mailing Address - Country:US
Mailing Address - Phone:321-727-7992
Mailing Address - Fax:321-727-7664
Practice Address - Street 1:1425 MALABAR RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2506
Practice Address - Country:US
Practice Address - Phone:321-434-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000603363L00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLKS071OtherMEDICARE
FL025119800Medicaid