Provider Demographics
NPI:1124023965
Name:GAGNER, DANIEL LAWRENCE
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:LAWRENCE
Last Name:GAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7470 NORMANDY CT
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4919
Mailing Address - Country:US
Mailing Address - Phone:727-393-1468
Mailing Address - Fax:727-319-0339
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2630
Practice Address - Country:US
Practice Address - Phone:813-558-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1560392367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301717600Medicaid
FL301717600Medicaid