Provider Demographics
NPI:1588701486
Name:GAGNE, DOREEN F (NP)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:F
Last Name:GAGNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 UPPER CHESAPEAKE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4360
Mailing Address - Country:US
Mailing Address - Phone:443-433-6663
Mailing Address - Fax:
Practice Address - Street 1:520 UPPER CHESAPEAKE DR STE 206
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4360
Practice Address - Country:US
Practice Address - Phone:410-879-9100
Practice Address - Fax:410-838-3853
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR094550363LF0000X
PASP010798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA867633OtherMEDICARE GROUP #
PASP010798OtherLICENSE
PA1007307260034OtherMEDICAID GROUP #
PAMG0883214OtherDEA
PAMG0883214OtherDEA