Provider Demographics
NPI:1568889954
Name:GAGNON, PETER JAMES (DPT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:GAGNON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-5081
Mailing Address - Country:US
Mailing Address - Phone:270-781-1151
Mailing Address - Fax:270-781-1959
Practice Address - Street 1:990 WILKINSON TRCE
Practice Address - Street 2:SUITE B1
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3404
Practice Address - Country:US
Practice Address - Phone:270-781-8040
Practice Address - Fax:270-781-8355
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist