Healthcare Provider Details

I. General information

NPI: 1962557207
Provider Name (Legal Business Name): LAVINA JACOB GAGNON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAVINA JOSE JACOB RPA-C

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST SUITE 900
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

2110 SILAS DEANE HWY
ROCKY HILL CT
06067-2313
US

V. Phone/Fax

Practice location:
  • Phone: 860-241-0700
  • Fax: 860-525-7881
Mailing address:
  • Phone: 860-258-3480
  • Fax: 860-571-6800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011516
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011516
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: