Provider Demographics
NPI:1346957594
Name:GAGNE, DEBRA J
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:GAGNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-2410
Mailing Address - Country:US
Mailing Address - Phone:605-303-4033
Mailing Address - Fax:
Practice Address - Street 1:17 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2410
Practice Address - Country:US
Practice Address - Phone:605-303-4033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD00204225342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD00204225OtherDRIVERS LICENSE