Healthcare Provider Details

I. General information

NPI: 1033160478
Provider Name (Legal Business Name): DAVID GHIORSE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 VERANDA ST MARTINS POINT HEALTH CARE
PORTLAND ME
04103-5545
US

IV. Provider business mailing address

PO BOX 9746
PORTLAND ME
04104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2402
  • Fax: 207-828-2425
Mailing address:
  • Phone: 207-791-3888
  • Fax: 207-828-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1367
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: