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NPI Code Detail

MEDICARE: MR. JACOB W SOUCY PA-S

MEDICARE: MR. JACOB W SOUCY PA-S
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1891359295
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JACOB W SOUCY PA-S
Provider Business Mailing Address
First Line : 716 STEVENS AVE
Second Line :
City : PORTLAND
State : ME
Zip : 04103-2693
Country : US
Telephone Number : 297-283-0171
Fax Number :
Provider Business Practice Location Address
First Line : 716 STEVENS AVE
Second Line :
City : PORTLAND
State : ME
Zip : 04103-2693
Country : US
Telephone Number : 297-283-0171
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/01/2019
Last Update Date : 05/01/2019

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