Provider Demographics
NPI:1437508389
Name:GAVIN, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:GAVIN
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 1:1256 W. LATHROP RD #376
Mailing Address - Street 2:
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330
Mailing Address - Country:US
Mailing Address - Phone:925-263-9331
Mailing Address - Fax:
Practice Address - Street 1:1256 W. LATHROP RD #376
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:925-263-9331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WV0202X
CA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171WV0202XOther Service ProvidersContractorVehicle Modifications