Healthcare Provider Details

I. General information

NPI: 1942091178
Provider Name (Legal Business Name): GABRIEL WILLIAM SUSEN AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORTHEAST DR
BANGOR ME
04401-4332
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-275-3800
  • Fax: 207-275-3836
Mailing address:
  • Phone: 207-973-5000
  • Fax: 207-973-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP251557
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN74008
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95271729
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: