Basic Information
| Provider Information | |||||||||
| NPI: | 1073614665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCAVOY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GALEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA MID LEVEL PRACTIT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 PLUMAS ST | ||||||||
| Address2: | STE A | ||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306712020 | ||||||||
| FaxNumber: | 5306716797 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 PLUMAS ST | ||||||||
| Address2: | STE A | ||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306712020 | ||||||||
| FaxNumber: | 5306716797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA13423 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MM0498419 | 01 | CA | DEA | OTHER | GR0070950 | 05 | CA | MEDICAID |