Healthcare Provider Details

I. General information

NPI: 1821084344
Provider Name (Legal Business Name): DIANE SMITH WRIGLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE L SMITH

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 SCHOONER ST
DAMARISCOTTA ME
04543-4051
US

IV. Provider business mailing address

PO BOX 745
NEWCASTLE ME
04553-0745
US

V. Phone/Fax

Practice location:
  • Phone: 207-563-4777
  • Fax:
Mailing address:
  • Phone: 207-563-4511
  • Fax: 207-563-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA499
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: