Provider Demographics
NPI:1083748214
Name:GAGNON, PATRICK LYNN (APRN)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:LYNN
Last Name:GAGNON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:PATRICK
Other - Middle Name:LYNN
Other - Last Name:GAGNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN CNS,BC
Mailing Address - Street 1:3017 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4977
Mailing Address - Country:US
Mailing Address - Phone:203-815-0691
Mailing Address - Fax:203-873-6845
Practice Address - Street 1:80 E BROADWAY APT D
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-6120
Practice Address - Country:US
Practice Address - Phone:203-815-0691
Practice Address - Fax:203-815-0691
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000894363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004174843Medicaid
CT890000235Medicare ID - Type Unspecified