Provider Demographics
NPI:1528418696
Name:GAGNE, DOMINIQUE (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:GAGNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E DUNLAP AVE STE 1-482
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-7806
Mailing Address - Country:US
Mailing Address - Phone:602-609-2600
Mailing Address - Fax:602-609-2601
Practice Address - Street 1:111 E DUNLAP AVE STE 1-482
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-7806
Practice Address - Country:US
Practice Address - Phone:602-609-2600
Practice Address - Fax:602-609-2601
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50171207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ246972OtherMEDICARE PTAN
AZ204096Medicaid