Provider Demographics
NPI:1700807484
Name:GAGON, MICHAEL (MPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GAGON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0933
Mailing Address - Country:US
Mailing Address - Phone:435-613-1500
Mailing Address - Fax:435-613-1501
Practice Address - Street 1:590 E 100 N
Practice Address - Street 2:SUITE 1
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2640
Practice Address - Country:US
Practice Address - Phone:435-613-1500
Practice Address - Fax:435-613-1501
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT292947-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005581101Medicare ID - Type Unspecified
UTP26477Medicare UPIN