Provider Demographics
NPI:1962099812
Name:ZIMMERMAN, GAVIN MARKUS
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:MARKUS
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5192 SASSAFRAS DR APT 311
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-7728
Mailing Address - Country:US
Mailing Address - Phone:608-799-9860
Mailing Address - Fax:
Practice Address - Street 1:5192 SASSAFRAS DR APT 311
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7728
Practice Address - Country:US
Practice Address - Phone:608-799-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN242508163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty