Physician Compare National (NPI:1417070905)

HEALTHCARE PROVIDER:

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1417070905
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	2264528868
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20160426001532
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	GAGNON
	Individual professional last name
Provider First Name	ELLIOTT
	Individual professional first name
Provider Middle Name	BRUCE
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OREGON HEALTH SCIENCES UNIVERSITY SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	2001
	Individual professional's medical school graduation year
Primary Specialty	PLASTIC AND RECONSTRUCTIVE SURGERY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	950 E BOGARD RD
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 209
	Group Practice or individual's line 2 address
City	WASILLA
	Group Practice or individual's city
State	AK
	Group Practice or individual's state
Zip Code	996547172
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	020006
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	MAT-SU REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y