Healthcare Provider Details

I. General information

NPI: 1508450677
Provider Name (Legal Business Name): KEVIN JOHN SHEASGREEN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 W MAIN ST
DOVER FOXCROFT ME
04426-1059
US

IV. Provider business mailing address

246 PARKVIEW AVE
BANGOR ME
04401-4063
US

V. Phone/Fax

Practice location:
  • Phone: 207-564-4464
  • Fax: 207-564-4461
Mailing address:
  • Phone: 781-252-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP201499
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: