Provider Demographics
NPI:1568460665
Name:GAGNON, CHAD (PA-C)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:GAGNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N INDIAN RD
Mailing Address - Street 2:
Mailing Address - City:SMITH RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95567-9509
Mailing Address - Country:US
Mailing Address - Phone:707-487-0215
Mailing Address - Fax:707-487-1304
Practice Address - Street 1:501 N INDIAN RD
Practice Address - Street 2:
Practice Address - City:SMITH RIVER
Practice Address - State:CA
Practice Address - Zip Code:95567-9509
Practice Address - Country:US
Practice Address - Phone:707-487-0215
Practice Address - Fax:707-487-1304
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP54160Medicare UPIN
CA0PA103960Medicare ID - Type Unspecified