Basic Information
Provider Information | |||||||||
NPI: | 1053423426 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAXWELL | ||||||||
FirstName: | LINDA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 WAYMAN LN | ||||||||
Address2: |   | ||||||||
City: | BAR HARBOR | ||||||||
State: | ME | ||||||||
PostalCode: | 046091625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072885081 | ||||||||
FaxNumber: | 2072888600 | ||||||||
Practice Location | |||||||||
Address1: | 16 COMMUNITY LN | ||||||||
Address2: |   | ||||||||
City: | SOUTHWEST HARBOR | ||||||||
State: | ME | ||||||||
PostalCode: | 046794273 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072445630 | ||||||||
FaxNumber: | 2072444418 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 03/06/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA362 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 432564399 | 05 | ME |   | MEDICAID |