Provider Demographics
NPI:1811137888
Name:GAGNON, JEFFREY (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GAGNON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 KENNEDY MEMORIAL DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4540
Mailing Address - Country:US
Mailing Address - Phone:207-861-7874
Mailing Address - Fax:207-861-4646
Practice Address - Street 1:180 KENNEDY MEMORIAL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4540
Practice Address - Country:US
Practice Address - Phone:207-861-7874
Practice Address - Fax:207-861-4646
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001156363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPA001156OtherSTATE LICENSE #