Provider Demographics
NPI:1992747141
Name:GAUTHIER, KATHY DAVIS (PA-C)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:DAVIS
Last Name:GAUTHIER
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 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-5500
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1054207RC0000X
CT001054363A00000X
MAPA4555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
010504OtherCONNECTICARE
290001054CT05OtherANTHEM/ECCD:06-1616101
2V7415OtherHELATHNET/ECCD:06-1616101
06-1616101OtherCOMM. HEALTH NETWORK/ECCD
06-1049086OtherCOMM. HEALTH NETWORK/ECCG
290001054CT03OtherANTHEM/ECCGH:06-1049086
2V7414OtherHEALTHNET/ECCG:06-1049086
500HBC444CT01OtherANTHEM:HOSP-BASED ECCD
290001054CT03OtherANTHEM/ECCGH:06-1049086
290001054CT05OtherANTHEM/ECCD:06-1616101
500HBC444CT01OtherANTHEM:HOSP-BASED ECCD