Provider Demographics
NPI:1518054030
Name:GAVARAS, ELAINE (NP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:GAVARAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4110
Mailing Address - Country:US
Mailing Address - Phone:715-735-4200
Mailing Address - Fax:
Practice Address - Street 1:3003 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI84586363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41251600Medicaid
MI104701210Medicaid
P00339753Medicare PIN