Basic Information
| Provider Information | |||||||||
| NPI: | 1235106808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAVINO | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GATMAITAN | ||||||||
| OtherFirstName: | GWENDOLYN | ||||||||
| OtherMiddleName: | Y | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7203 W DESCHUTES AVE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097371880 | ||||||||
| FaxNumber: | 5097371879 | ||||||||
| Practice Location | |||||||||
| Address1: | 7211 W DESCHUTES AVE | ||||||||
| Address2: | STE. E | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097359239 | ||||||||
| FaxNumber: | 5097359310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 052069 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000971022A | 05 | GA | MEDICAID | 000971022B | 05 | GA | MEDICAID |