Provider Demographics
NPI:1750499232
Name:GAVACH, JAMES A (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:GAVACH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3450
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-3450
Mailing Address - Country:US
Mailing Address - Phone:605-719-8289
Mailing Address - Fax:605-719-7680
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-719-8289
Practice Address - Fax:605-719-7680
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2008-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR031455367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5753332Medicaid
SD0040909OtherWELLMARK
SD5753330Medicaid
SD430079097OtherRR MEDICARE
SD5753332Medicaid