Provider Demographics
NPI:1033129846
Name:GAGNON, PATRICIA JO (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JO
Last Name:GAGNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 STONE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5227
Mailing Address - Country:US
Mailing Address - Phone:207-626-3455
Mailing Address - Fax:207-626-3612
Practice Address - Street 1:66 STONE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5227
Practice Address - Country:US
Practice Address - Phone:207-626-3455
Practice Address - Fax:207-626-3612
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PO3074Medicare UPIN
AP1238Medicare ID - Type Unspecified