Provider Demographics
NPI:1396100749
Name:GAGIANAS, THEODORE MARINO EZEKIEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:MARINO EZEKIEL
Last Name:GAGIANAS
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:1995 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-2423
Mailing Address - Country:US
Mailing Address - Phone:330-332-7840
Mailing Address - Fax:330-332-7847
Practice Address - Street 1:1995 E STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2423
Practice Address - Country:US
Practice Address - Phone:330-332-7840
Practice Address - Fax:330-332-7847
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA058003363AS0400X
PAOA003697363AS0400X
OH50.007297363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA467605NH3Medicare PIN