Provider Demographics
NPI:1598778292
Name:GAVIN, ANGELA AYOTTE
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:AYOTTE
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 1:282 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-3377
Mailing Address - Country:US
Mailing Address - Phone:315-769-5520
Mailing Address - Fax:
Practice Address - Street 1:155 FINNEY BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1067
Practice Address - Country:US
Practice Address - Phone:518-483-0109
Practice Address - Fax:518-483-0115
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006074 1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician