Healthcare Provider Details

I. General information

NPI: 1194130716
Provider Name (Legal Business Name): NICOLE LESSARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 01/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 BRAMHALL ST
PORTLAND ME
04102
US

IV. Provider business mailing address

27 BRAMHALL ST
PORTLAND ME
04102
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2134
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: