Provider Demographics
NPI:1760015788
Name:GAGNE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SOUHEGAN DR
Mailing Address - Street 2:
Mailing Address - City:MERRIMACK
Mailing Address - State:NH
Mailing Address - Zip Code:03054-3626
Mailing Address - Country:US
Mailing Address - Phone:603-438-3276
Mailing Address - Fax:
Practice Address - Street 1:881 MARLBORO RD
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-5617
Practice Address - Country:US
Practice Address - Phone:877-932-6757
Practice Address - Fax:603-415-2489
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder