Basic Information
| Provider Information | |||||||||
| NPI: | 1821004524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAGNON | ||||||||
| FirstName: | SUZANNE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1691 GALISTEO ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059541921 | ||||||||
| FaxNumber: | 5059541922 | ||||||||
| Practice Location | |||||||||
| Address1: | 1691 GALISTEO ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059541921 | ||||||||
| FaxNumber: | 5059541922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 09/26/2014 | ||||||||
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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 | 363LF0000X | CNP00752 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000N4725 | 05 | NM | MEDICAID |