Healthcare Provider Details

I. General information

NPI: 1245453604
Provider Name (Legal Business Name): LINDA JANE MASTRO CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 EDGEMONT DR
PRESQUE ISLE ME
04769-2016
US

IV. Provider business mailing address

PO BOX 287
PORTAGE LAKE ME
04768-0287
US

V. Phone/Fax

Practice location:
  • Phone: 207-768-2803
  • Fax: 207-760-1159
Mailing address:
  • Phone: 207-435-2850
  • Fax: 207-760-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number031908
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: