Healthcare Provider Details

I. General information

NPI: 1790704625
Provider Name (Legal Business Name): WALTER N HEARN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 BARNARD LN
KENNEBUNK ME
04043-6714
US

IV. Provider business mailing address

26 BARNARD LN
KENNEBUNK ME
04043-6714
US

V. Phone/Fax

Practice location:
  • Phone: 207-502-7074
  • Fax:
Mailing address:
  • Phone: 207-502-7074
  • Fax: 207-985-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-060
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier002421
Identifier TypeOTHER
Identifier StateME
Identifier IssuerANTHEM BC/BS
# 2
Identifier142492
Identifier TypeOTHER
Identifier StateME
Identifier IssuerUSHC
# 3
Identifier010378298
Identifier TypeOTHER
Identifier StateME
Identifier IssuerMACHIGONNE
# 4
Identifier0518560
Identifier TypeOTHER
Identifier StateME
Identifier IssuerCIGNA
# 5
Identifier295630099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer
# 6
IdentifierDO3850
Identifier TypeOTHER
Identifier StateME
Identifier IssuerHARVARD PILGRIM
# 7
Identifier080044502
Identifier TypeOTHER
Identifier StateME
Identifier IssuerRAILROAD MEDICARE
# 8
Identifier295630099
Identifier TypeOTHER
Identifier StateME
Identifier IssuerPRIMECARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: