Provider Demographics
NPI:1558117721
Name:GAGNON, KEITH BOE (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:BOE
Last Name:GAGNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 KNOLLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1702
Mailing Address - Country:US
Mailing Address - Phone:208-589-4311
Mailing Address - Fax:
Practice Address - Street 1:275 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1155
Practice Address - Country:US
Practice Address - Phone:276-223-0242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program