Basic Information
| Provider Information | |||||||||
| NPI: | 1336186568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRATZER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FODEN RD. WEST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 84 MARGINAL WAY | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077745816 | ||||||||
| FaxNumber: | 2075238597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R034508 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | AP081018 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 432799999 | 05 | ME | MEDICAID |