=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609852086
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN PETRIN FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2005
-----------------------------------------------------
Last Update Date | 04/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 JUNE ST
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04073-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-490-7860
-----------------------------------------------------
Fax | 207-604-7409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MEDICAL CENTER DR
-----------------------------------------------------
City | BIDDEFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04005-9422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-283-7000
-----------------------------------------------------
Fax | 207-282-9128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CNP81444
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------