Basic Information
Provider Information
NPI: 1952767394
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GAGGINI
FirstName: ALEXIS
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3269 N STOCKTON HILL RD
Address2:  
City: KINGMAN
State: AZ
PostalCode: 864093619
CountryCode: US
TelephoneNumber: 3286818738
FaxNumber:  
Practice Location
Address1: 1739 E BEVERLY AVE
Address2: STE 107
City: KINGMAN
State: AZ
PostalCode: 864093593
CountryCode: US
TelephoneNumber: 9286818738
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/14/2016
LastUpdateDate: 02/10/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1835P2201XRPH.03335159-3OHN    
1835P2201XRP445567PAN    
1835P2201X2010031678MOY    
1835P2201XS022273AZN    

No ID Information.


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