Healthcare Provider Details

I. General information

NPI: 1508968298
Provider Name (Legal Business Name): ANDREA GATCOMB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VA CTR
AUGUSTA ME
04330-6719
US

IV. Provider business mailing address

219 METCALF RD
WINTHROP ME
04364-3371
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax: 207-621-7315
Mailing address:
  • Phone: 207-623-8411
  • Fax: 207-621-7315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI662
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: