=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679532436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL MARC GAGNON D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2006
-----------------------------------------------------
Last Update Date | 08/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 PARK STREET
-----------------------------------------------------
City | HYANNIS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-862-5315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 MORSE RD
-----------------------------------------------------
City | SANDWICH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02563-2276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-413-9294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 75332
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------