1962557207 NPI number — MRS. LAVINA JACOB GAGNON PA-C

Table of content: MRS. LAVINA JACOB GAGNON PA-C (NPI 1962557207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962557207 NPI number — MRS. LAVINA JACOB GAGNON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAGNON
Provider First Name:
LAVINA
Provider Middle Name:
JACOB
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACOB
Provider Other First Name:
LAVINA
Provider Other Middle Name:
JOSE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962557207
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2110 SILAS DEANE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-2313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-258-3480
Provider Business Mailing Address Fax Number:
860-571-6800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 SEYMOUR ST
Provider Second Line Business Practice Location Address:
SUITE 900
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-5501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-241-0700
Provider Business Practice Location Address Fax Number:
860-525-7881
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  011516 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 011516 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 011516 . This is a "LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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