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General NPI Number Information
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NPI Number | 1265193148
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Entity Type | Individual
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Provider Name | SAMUEL RICHARD FORD
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Gender | Male
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Dates
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Enumeration Date | 01/04/2022
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 925 UNION ST STE 3
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City | BANGOR
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State | ME
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Zip | 04401-3051
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Country | US
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Telephone | 207-973-9980
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Fax |
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Provider Business Mailing Address
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Address Line | 925 UNION ST STE 3
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City | BANGOR
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State | ME
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Zip | 04401-3051
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA2618
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License Number State | ME
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