Basic Information
| Provider Information | |||||||||
| NPI: | 1992747141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | DAVIS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177325500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177325500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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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 | 207RC0000X | 1054 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363A00000X | 001054 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA4555 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 010504 | 01 | CONNECTICARE | OTHER | 290001054CT05 | 01 | ANTHEM/ECCD:06-1616101 | OTHER | 2V7415 | 01 | HELATHNET/ECCD:06-1616101 | OTHER | 06-1616101 | 01 | COMM. HEALTH NETWORK/ECCD | OTHER | 06-1049086 | 01 | COMM. HEALTH NETWORK/ECCG | OTHER | 290001054CT03 | 01 | ANTHEM/ECCGH:06-1049086 | OTHER | 2V7414 | 01 | HEALTHNET/ECCG:06-1049086 | OTHER | 500HBC444CT01 | 01 | ANTHEM:HOSP-BASED ECCD | OTHER |