Healthcare Provider Details

I. General information

NPI: 1598460099
Provider Name (Legal Business Name): NIKOLA CHARLEEN RADLACH-BARNACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GANNETT DR STE B
SOUTH PORTLAND ME
04106-5900
US

IV. Provider business mailing address

100 GANNETT DR STE B
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-401-4353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number202740
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: