Healthcare Provider Details

I. General information

NPI: 1043743214
Provider Name (Legal Business Name): DYLAN WINGFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

324 GANNETT DR STE 200
SOUTH PORTLAND ME
04106-3266
US

V. Phone/Fax

Practice location:
  • Phone: 207-478-6024
  • Fax:
Mailing address:
  • Phone: 207-482-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD24848
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: