Provider Demographics
NPI:1871601948
Name:GAGNON, MARY ANN (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GAGNON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:207-451-9600
Mailing Address - Fax:207-451-9603
Practice Address - Street 1:31 COLCORD ST
Practice Address - Street 2:
Practice Address - City:SOUTH BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03908-1004
Practice Address - Country:US
Practice Address - Phone:207-384-4949
Practice Address - Fax:207-384-4273
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH029774-23363LP2300X
MECNP81271363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3075766Medicaid
MEP00991109OtherRR MEDICARE
NH500022875OtherRR MEDICARE
ME1871601948Medicaid
NHNP091303Medicare PIN
NH500022875OtherRR MEDICARE
MEP00991109OtherRR MEDICARE