Provider Demographics
NPI:1326382805
Name:GAVIN, JOSH DANIEL (PTA)
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:DANIEL
Last Name:GAVIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MN
Mailing Address - Zip Code:55334-2297
Mailing Address - Country:US
Mailing Address - Phone:507-237-8730
Mailing Address - Fax:
Practice Address - Street 1:640 3RD ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334-2297
Practice Address - Country:US
Practice Address - Phone:507-237-8730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1455225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant