Basic Information
| Provider Information | |||||||||
| NPI: | 1194981860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINNON-LEACH | ||||||||
| FirstName: | ESSIE | ||||||||
| MiddleName: | Y. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PLACE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076616654 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 BEACH ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040722810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072821500 | ||||||||
| FaxNumber: | 2072826606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2008 | ||||||||
| LastUpdateDate: | 05/04/2015 | ||||||||
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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 | 363A00000X | PA1180 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 434701399 | 05 | ME | MEDICAID |