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NPI Code Detail

MEDICARE: MR. MARC DYLAN GAGNON PMHNP-BC

MEDICARE: MR. MARC DYLAN GAGNON PMHNP-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse Practitioner12627CT

General Provider Information

NPI Number : 1508631623
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARC DYLAN GAGNON PMHNP-BC
Provider Business Mailing Address
First Line : 271 LOCUST RD
Second Line :
City : HARWINTON
State : CT
Zip : 06791-2412
Country : US
Telephone Number : 203-233-8444
Fax Number :
Provider Business Practice Location Address
First Line : 21 WATERVILLE RD
Second Line :
City : AVON
State : CT
Zip : 06001-2097
Country : US
Telephone Number : 860-284-0182
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/20/2023
Last Update Date : 03/10/2026

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