Healthcare Provider Details

I. General information

NPI: 1831668342
Provider Name (Legal Business Name): TYLER LEE JAMISON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 UNION ST STE 3
BANGOR ME
04401-3051
US

IV. Provider business mailing address

66 CHARLES ST
BANGOR ME
04401-4651
US

V. Phone/Fax

Practice location:
  • Phone: 207-974-7400
  • Fax:
Mailing address:
  • Phone: 207-592-5580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberAT662
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: