Basic Information
| Provider Information | |||||||||
| NPI: | 1598860868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEBRETON-GAUTHIER | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
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| Practice Location | |||||||||
| Address1: | 417 STATE ST | ||||||||
| Address2: | STE 221 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079739949 | ||||||||
| FaxNumber: | 2079739555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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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 | PA-1444 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 432205999 | 05 | ME | MEDICAID |