Healthcare Provider Details

I. General information

NPI: 1629507934
Provider Name (Legal Business Name): SEBASTIAN GONZALES REYES JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

6 POND VIEW RD
CAPE ELIZABETH ME
04107-2603
US

V. Phone/Fax

Practice location:
  • Phone: 207-661-5410
  • Fax:
Mailing address:
  • Phone: 857-221-6466
  • Fax: 857-221-6466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN2270507
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number114842-23
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA193015
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: