1396856670 NPI number — LORI I GAGNON MD PA

Table of content: (NPI 1396856670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396856670 NPI number — LORI I GAGNON MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LORI I GAGNON MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396856670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 CULLY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-5950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-258-7383
Provider Business Mailing Address Fax Number:
830-258-7055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 CULLY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-5950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-258-7383
Provider Business Practice Location Address Fax Number:
830-258-7055
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAGNON
Authorized Official First Name:
LORI
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
830-258-7185

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0039NX . This is a "BC GRP" identifier . This identifiers is of the category "OTHER".
  • Identifier: DF5642 . This is a "RAILROAD MCR GRP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 184196701 . This is a "MCD INDV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 184195901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00375637 . This is a "RAILROAD INDV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8W5070 . This is a "BC INDV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8F4161 . This is a "MCR INDV" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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