Provider Demographics
NPI:1558904813
Name:GAGNON, JOSEPH RICHARD JR (CRNP)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:RICHARD
Last Name:GAGNON
Suffix:JR
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WEST THIRD AVENUE
Mailing Address - Street 2:PO BOX 26301
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-0301
Mailing Address - Country:US
Mailing Address - Phone:267-718-0498
Mailing Address - Fax:
Practice Address - Street 1:3774 RIDGE PIKE REAR 2
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-3153
Practice Address - Country:US
Practice Address - Phone:610-489-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN631678163WP0808X
PASP021305363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health