Basic Information
| Provider Information | |||||||||
| NPI: | 1316279235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SQUIRES | ||||||||
| FirstName: | DIXIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SQUIRES | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | DIXIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 BRAMHALL ST | ||||||||
| Address2: | CARDIAC SERVICES | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076620111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22 BRAMHALL ST | ||||||||
| Address2: | CARDIAC SERVICES | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076620111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 05/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA001189 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.