Provider Demographics
NPI:1902514680
Name:MAYO, GAVIN CASEY
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:CASEY
Last Name:MAYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-1089
Mailing Address - Country:US
Mailing Address - Phone:985-892-7070
Mailing Address - Fax:985-892-7017
Practice Address - Street 1:200 COURSE DRIVE
Practice Address - Street 2:SUITE M
Practice Address - City:CARRIERE
Practice Address - State:MS
Practice Address - Zip Code:39426-9037
Practice Address - Country:US
Practice Address - Phone:769-242-3185
Practice Address - Fax:769-242-0099
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily