Provider Demographics
NPI:1639198492
Name:GAVULA, PATRICIA M (PA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:GAVULA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FISHER RD
Mailing Address - Street 2:PO BOX 547
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602-9516
Mailing Address - Country:US
Mailing Address - Phone:802-371-4100
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT900210Medicaid
AP2075Medicare ID - Type Unspecified
VT900210Medicaid