Provider Demographics
NPI:1578928628
Name:GAGNON PLASTIC AND RECONSTRUCTIVE SURGERY
Entity Type:Organization
Organization Name:GAGNON PLASTIC AND RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:B
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-407-8726
Mailing Address - Street 1:950 E BOGARD RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7184
Mailing Address - Country:US
Mailing Address - Phone:907-357-4550
Mailing Address - Fax:907-357-4552
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 209
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-357-4550
Practice Address - Fax:907-357-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104918208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty