Basic Information
| Provider Information | |||||||||
| NPI: | 1265422943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHADWICK | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROLLENDER | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
| FaxNumber: | 2077957133 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
| FaxNumber: | 2077957133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA631 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 010416156 | 01 | CIGNA / GREAT WEST | OTHER | 201017 | 01 | MEDICARE ASC FACILITY | OTHER | 261500099 | 05 | ME | MEDICAID | MM0716 | 01 | MEDICARE CLINIC FACILITY | OTHER | 010416156 | 01 | CORE / MEDNET / TRAVELERS | OTHER | 0378600001 | 01 | DMERC | OTHER | AP1070 | 01 | PTAN | OTHER | 025716 | 01 | ANTHEM | OTHER | 100294000 | 01 | USPS WC | OTHER | 970026374 | 01 | RR MEDICARE | OTHER | 1044480 | 01 | AETNA | OTHER |