Healthcare Provider Details

I. General information

NPI: 1790734861
Provider Name (Legal Business Name): STEPHEN BENNETT BUERGIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 HIGH ST
LEWISTON ME
04240-7616
US

IV. Provider business mailing address

60 HIGH ST
LEWISTON ME
04240-7616
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-8260
  • Fax:
Mailing address:
  • Phone: 207-795-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2169-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1405
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: