Healthcare Provider Details

I. General information

NPI: 1316496052
Provider Name (Legal Business Name): KASSIE A SKVORAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KASSIE REUTLINGER PA-C

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 07/21/2022
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ACADEMY RD
MONMOUTH ME
04259-7035
US

IV. Provider business mailing address

PO BOX 9746
PORTLAND ME
04104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 207-524-3501
  • Fax: 207-933-9645
Mailing address:
  • Phone: 207-791-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1648
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: