Basic Information
| Provider Information | |||||||||
| NPI: | 1588701486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAGNE | ||||||||
| FirstName: | DOREEN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | C.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211462115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7172174217 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 NORLAND AVENUE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172176870 | ||||||||
| FaxNumber: | 7172176945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 164W00000X | MD | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | SP010798 | 01 | PA | LICENSE | OTHER | 1007307260034 | 01 | PA | MEDICAID GROUP # | OTHER | MG0883214 | 01 | PA | DEA | OTHER |