Basic Information
| Provider Information | |||||||||
| NPI: | 1669530663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | MAURA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74647 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441940730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408790081 | ||||||||
| FaxNumber: | 4408790084 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441227024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164916000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50-001272 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.