Healthcare Provider Details

I. General information

NPI: 1376494641
Provider Name (Legal Business Name): LOU ANTHONINE GAGARIN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 LONG BEACH BLVD
LONG BEACH CA
90807-3315
US

IV. Provider business mailing address

3641E 29TH ST
HIGHLAND CA
92346-1966
US

V. Phone/Fax

Practice location:
  • Phone: 424-402-0661
  • Fax:
Mailing address:
  • Phone: 424-402-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95038404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: