Provider Demographics
NPI:1962557207
Name:GAGNON, LAVINA JACOB (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAVINA
Middle Name:JACOB
Last Name:GAGNON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LAVINA
Other - Middle Name:JOSE
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:2110 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2313
Mailing Address - Country:US
Mailing Address - Phone:860-258-3480
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 900
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-241-0700
Practice Address - Fax:860-525-7881
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011516363A00000X
CT011516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT011516OtherLICENSE