Provider Demographics
NPI:1407506942
Name:GAVILANES, MARIAELENA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIAELENA
Middle Name:
Last Name:GAVILANES
Suffix:
Gender:F
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 1:34 GREENMOOR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-7474
Mailing Address - Country:US
Mailing Address - Phone:626-862-7094
Mailing Address - Fax:
Practice Address - Street 1:32406 COAST HWY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-6783
Practice Address - Country:US
Practice Address - Phone:949-499-4147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60874208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery