Provider Demographics
NPI:1316983836
Name:GAGNON, CAREY A (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CAREY
Middle Name:A
Last Name:GAGNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 N HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3114
Mailing Address - Country:US
Mailing Address - Phone:724-347-1004
Mailing Address - Fax:
Practice Address - Street 1:1075 N HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3114
Practice Address - Country:US
Practice Address - Phone:724-347-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052114363A00000X
OHOA001002363A00000X
OH50002382207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA098771K0SMedicare ID - Type Unspecified
OHGAPA26531Medicare ID - Type Unspecified
Q28841Medicare UPIN