Basic Information
| Provider Information | |||||||||
| NPI: | 1467749184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | GNP, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546015429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087827300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 GOPHER DR | ||||||||
| Address2: | |||||||||
| City: | TOMAH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546604513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083724111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 2057 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LG0600X | 2057 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.