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General NPI Number Information
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NPI Number | 1982815064
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Entity Type | Organization
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Legal Business Name | SHANE D GAGON MD, PC
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 12/01/2010
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Provider Practice Location Address
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Address Line | 377 NO. FAIRGROUNDS RD.
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City | PRICE
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State | UT
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Zip | 84501-4211
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Country | US
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Telephone | 435-613-2200
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Fax | 435-613-2201
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Provider Business Mailing Address
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Address Line | 377 NO. FAIRGOUNDS RD.
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City | PRICE
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State | UT
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Zip | 84501-4216
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Country | US
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Telephone | 435-613-2200
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Fax | 435-613-2201
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Authorized Official
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Title or Position | BILLING
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Name | PAT A STAPLEY
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Credential |
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Telephone | 435-613-2210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 361555-1205
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License Number State | UT
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