Provider Demographics
NPI:1619056637
Name:GAVIGAN, NORA JEANNE (MD)
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:JEANNE
Last Name:GAVIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NORA
Other - Middle Name:JEANNE
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9680 TAMARACK RD, STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-738-0470
Mailing Address - Fax:651-738-0470
Practice Address - Street 1:9680 TAMARACK RD, STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-738-0470
Practice Address - Fax:651-738-0470
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46546208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I50393Medicare UPIN