Provider Demographics
NPI:1548826605
Name:GAGNON, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLEFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:79339-4899
Mailing Address - Country:US
Mailing Address - Phone:806-385-6411
Mailing Address - Fax:
Practice Address - Street 1:1500 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:LITTLEFIELD
Practice Address - State:TX
Practice Address - Zip Code:79339-4899
Practice Address - Country:US
Practice Address - Phone:806-385-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT2166207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program