Provider Demographics
NPI:1467087148
Name:PETERS, GAVIN PAUL (PA)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:PAUL
Last Name:PETERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:107 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1002
Practice Address - Country:US
Practice Address - Phone:920-846-3092
Practice Address - Fax:920-846-8313
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1172149OtherNATIONAL COMM ON CERTIFICATION OF PHYSICIAN ASSISTANCES