Healthcare Provider Details

I. General information

NPI: 1144889403
Provider Name (Legal Business Name): EVAN MARK PARADIS BS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIDDLE ST APT 1
OLD TOWN ME
04468-1480
US

IV. Provider business mailing address

100 MIDDLE ST APT 1
OLD TOWN ME
04468-1480
US

V. Phone/Fax

Practice location:
  • Phone: 207-659-9621
  • Fax:
Mailing address:
  • Phone: 207-659-9621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT459
License Number StateME

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: