Provider Demographics
NPI:1457831695
Name:GAGNER, JOSHUA MICHAEL (BA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MICHAEL
Last Name:GAGNER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8218 S PEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-6113
Mailing Address - Country:US
Mailing Address - Phone:918-527-6314
Mailing Address - Fax:
Practice Address - Street 1:650 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-4429
Practice Address - Country:US
Practice Address - Phone:918-587-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator