Healthcare Provider Details

I. General information

NPI: 1689307985
Provider Name (Legal Business Name): ANGELICA G MUSHENKO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ANCHOR DR STE 102
ROCKPORT ME
04856-3847
US

IV. Provider business mailing address

15 ANCHOR DR STE 102
ROCKPORT ME
04856-3847
US

V. Phone/Fax

Practice location:
  • Phone: 207-301-3660
  • Fax: 207-301-5160
Mailing address:
  • Phone: 207-301-3660
  • Fax: 207-301-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3090
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: