Provider Demographics
NPI:1396856670
Name:LORI I GAGNON MD PA
Entity Type:Organization
Organization Name:LORI I GAGNON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:I
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-258-7185
Mailing Address - Street 1:260 CULLY DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5950
Mailing Address - Country:US
Mailing Address - Phone:830-258-7383
Mailing Address - Fax:830-258-7055
Practice Address - Street 1:260 CULLY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5950
Practice Address - Country:US
Practice Address - Phone:830-258-7383
Practice Address - Fax:830-258-7055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0039NXOtherBC GRP
DF5642OtherRAILROAD MCR GRP
184196701OtherMCD INDV
TX184195901Medicaid
P00375637OtherRAILROAD INDV
8W5070OtherBC INDV
TX8F4161OtherMCR INDV
0039NXOtherBC GRP
P00375637OtherRAILROAD INDV