MEDICARE: MS. LAURIE MARTENS PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA52	ME

General Provider Information

NPI Number	:	1215906904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURIE MARTENS PAC

Provider Business Mailing Address
First Line	:	100 FODEN RD W
Second Line	:	STE 203
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2327
Country	:	US
Telephone Number	:	207-828-0361
Fax Number	:	207-874-1483

Provider Business Practice Location Address
First Line	:	100 FODEN RD E
Second Line	:	STE 203
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2327
Country	:	US
Telephone Number	:	207-874-1489
Fax Number	:	207-523-8590

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	11/23/2010

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