Provider Demographics
NPI:1730371998
Name:PAVLUE, BRIAN T (PAC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:T
Last Name:PAVLUE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E MINERAL RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4461
Mailing Address - Country:US
Mailing Address - Phone:917-301-4953
Mailing Address - Fax:
Practice Address - Street 1:1225 E MINERAL RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-4461
Practice Address - Country:US
Practice Address - Phone:917-301-4953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1972023207P00000X
AZ4384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine