Basic Information
Provider Information | |||||||||
NPI: | 1124314513 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN WAGENEN | ||||||||
FirstName: | ERIN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 GANNETT DRIVE | ||||||||
Address2: | SUITE C | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 04106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078280361 | ||||||||
FaxNumber: | 2076627066 | ||||||||
Practice Location | |||||||||
Address1: | 259 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | YARMOUTH | ||||||||
State: | ME | ||||||||
PostalCode: | 04096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078469602 | ||||||||
FaxNumber: | 2076627066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2011 | ||||||||
LastUpdateDate: | 11/05/2014 | ||||||||
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 | 208000000X | MD20134 | ME | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.