Basic Information
| Provider Information | |||||||||
| NPI: | 1225533821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | DEHAAN | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAKKENBERG | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | DEHAAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 964 ALLEN POND RD | ||||||||
| Address2: | |||||||||
| City: | GREENE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042363702 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD24493 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.