Healthcare Provider Details

I. General information

NPI: 1033289269
Provider Name (Legal Business Name): LAKES REGION SURGICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 COUNTRY CLUB RD VILLAGE WEST, BUILDING 7
GILFORD NH
03249-6972
US

IV. Provider business mailing address

PO BOX 1328
AUBURN ME
04211-1328
US

V. Phone/Fax

Practice location:
  • Phone: 603-528-1547
  • Fax: 603-524-5536
Mailing address:
  • Phone: 207-784-9185
  • Fax: 207-784-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNH

VIII. Authorized Official

Name: NICOLA SHAFIQUE
Title or Position: OFFICE MANAGER
Credential:
Phone: 603-528-1547