Healthcare Provider Details

I. General information

NPI: 1578928628
Provider Name (Legal Business Name): GAGNON PLASTIC AND RECONSTRUCTIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 E BOGARD RD SUITE 209
WASILLA AK
99654-7184
US

IV. Provider business mailing address

950 E BOGARD RD SUITE 209
WASILLA AK
99654-7184
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-4550
  • Fax: 907-357-4552
Mailing address:
  • Phone: 907-357-4550
  • Fax: 907-357-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number104918
License Number StateAK

VIII. Authorized Official

Name: DR. ELLIOTT B GAGNON
Title or Position: OWNER
Credential: MD
Phone: 707-407-8726