Provider Demographics
NPI:1952308272
Name:GAVINS, PAUL KENNETH (PA-C)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:KENNETH
Last Name:GAVINS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-3447
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-3447
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2328-023363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1952308272Medicaid
WI60846OtherDEAN HEALTH INSURANCE
WI166774150Medicare PIN