Basic Information
Provider Information | |||||||||
NPI: | 1861620627 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAVIN | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3900 S ZINTEL WAY | ||||||||
Address2: |   | ||||||||
City: | KENNEWICK | ||||||||
State: | WA | ||||||||
PostalCode: | 993375092 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423627 | ||||||||
FaxNumber: | 5099422268 | ||||||||
Practice Location | |||||||||
Address1: | 1100 GOETHALS DRIVE | ||||||||
Address2: | SUITE D KADLEC CLINIC UROLOGY | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 99352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423165 | ||||||||
FaxNumber: | 5099423167 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2009 | ||||||||
LastUpdateDate: | 05/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 5101018466 | MI | N |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | OP60479551 | WA | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.