Healthcare Provider Details

I. General information

NPI: 1376612671
Provider Name (Legal Business Name): ELIZABETH WHITNEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600B CONGRESS ST
PORTLAND ME
04102
US

IV. Provider business mailing address

1600B CONGRESS ST
PORTLAND ME
04102-2124
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-5222
  • Fax:
Mailing address:
  • Phone: 207-774-5222
  • Fax: 207-761-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA897
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-897
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: