Healthcare Provider Details

I. General information

NPI: 1558089276
Provider Name (Legal Business Name): MICHAEL C TAVARES PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 CORPORATE DR
BANGOR ME
04401-4314
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-2636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11022135
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP241426
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: