Provider Demographics
NPI:1982815064
Name:SHANE D GAGON MD, PC
Entity Type:Organization
Organization Name:SHANE D GAGON MD, PC
Other - Org Name:CASTLE COUNTRY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:STAPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-613-2210
Mailing Address - Street 1:377 NO. FAIRGOUNDS RD.
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4216
Mailing Address - Country:US
Mailing Address - Phone:435-613-2200
Mailing Address - Fax:435-613-2201
Practice Address - Street 1:377 NO. FAIRGROUNDS RD.
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4211
Practice Address - Country:US
Practice Address - Phone:435-613-2200
Practice Address - Fax:435-613-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361555-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDF8294OtherRAILROAD MEDICARE
UT529513346027Medicaid
UT000061596Medicare PIN
UTG76999Medicare UPIN