Provider Demographics
NPI:1801332507
Name:GAUVIN, MARK RYAN (MS, MSPAS, RD, PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RYAN
Last Name:GAUVIN
Suffix:
Gender:M
Credentials:MS, MSPAS, RD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 W MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-6301
Mailing Address - Country:US
Mailing Address - Phone:401-606-3111
Mailing Address - Fax:
Practice Address - Street 1:1360 W MAIN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-6301
Practice Address - Country:US
Practice Address - Phone:401-606-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00892133V00000X
RIPA01375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110178471AOtherMASSHEALTH