Basic Information
| Provider Information | |||||||||
| NPI: | 1023372117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078742141 | ||||||||
| FaxNumber: | 2078742164 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078282402 | ||||||||
| FaxNumber: | 2078282425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2012 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 21443315 | ME | N | Nursing Service Providers | Registered Nurse | 363L00000X | CNP121035 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.