Healthcare Provider Details

I. General information

NPI: 1700024783
Provider Name (Legal Business Name): CRYSTAL LEE MACCLINTOCK RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 W MAIN ST SUITE 200
DOVER FOXCROFT ME
04426-1059
US

IV. Provider business mailing address

891 W MAIN ST SUITE 200
DOVER FOXCROFT ME
04426-1059
US

V. Phone/Fax

Practice location:
  • Phone: 207-564-4464
  • Fax:
Mailing address:
  • Phone: 207-564-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1455
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: