=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619772555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL HARCOURT PA-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2025
-----------------------------------------------------
Last Update Date | 01/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 ENTERPRISE DR STE 100
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-7998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-621-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 FOREST AVE
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04021-3008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-748-6052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA2976
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------