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General NPI Number Information
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NPI Number | 1558089276
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Entity Type | Individual
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Provider Name | MICHAEL C TAVARES PMHNP
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Gender | Male
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Dates
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Enumeration Date | 08/18/2022
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Last Update Date | 10/28/2024
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Provider Practice Location Address
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Address Line | 181 CORPORATE DR
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City | BANGOR
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State | ME
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Zip | 04401-4314
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Country | US
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Telephone | 207-992-2636
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1599
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City | BANGOR
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State | ME
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Zip | 04402-1599
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN11022135
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CNP241426
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License Number State | ME
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