Provider Demographics
NPI:1194394775
Name:GAGNON, TANNER ALAN
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:ALAN
Last Name:GAGNON
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 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3069 UNIVERSITY DR STE 230
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2322
Practice Address - Country:US
Practice Address - Phone:248-243-8770
Practice Address - Fax:248-243-8771
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303367225100000X
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist