Healthcare Provider Details

I. General information

NPI: 1366525826
Provider Name (Legal Business Name): LISA MARIE ANDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE GOURLEY MS, PA-C

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WHITTEN RD
AUGUSTA ME
04330-6019
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 207-466-2400
  • Fax:
Mailing address:
  • Phone: 603-410-6700
  • Fax: 603-319-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1830
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003392
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0003392
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: