Provider Demographics
NPI:1366161192
Name:GAGNON, RYAN MICHAEL (RN, BSN, CPEN)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:GAGNON
Suffix:
Gender:M
Credentials:RN, BSN, CPEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-1106
Mailing Address - Country:US
Mailing Address - Phone:708-567-7190
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:708-567-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN227557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse