Healthcare Provider Details

I. General information

NPI: 1598153082
Provider Name (Legal Business Name): EDWARD DEVEAU JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST
BANGOR ME
04401
US

IV. Provider business mailing address

141 N MAIN ST STE # 205
BREWER ME
04412-2011
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-4519
  • Fax: 207-992-4034
Mailing address:
  • Phone: 207-992-4032
  • Fax: 207-992-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number089493-23
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA143061
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: