Provider Demographics
NPI:1215146311
Name:GAVAN, CATHERINE LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:LYNN
Last Name:GAVAN
Suffix:
Gender:F
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 1:54220 MAPLE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-6013
Mailing Address - Country:US
Mailing Address - Phone:586-697-6152
Mailing Address - Fax:
Practice Address - Street 1:48681 HAYES RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4403
Practice Address - Country:US
Practice Address - Phone:586-799-1212
Practice Address - Fax:586-799-1210
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1755014270OtherBCBS OF MICHIGAN
MICG002698OtherMICHIGAN STATE LICENSE
MIMG0885939OtherDEA NUMBER
MI0P8960002Medicare PIN
MI573711Medicare UPIN