Basic Information
| Provider Information | |||||||||
| NPI: | 1417026634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WORMWOOD | ||||||||
| FirstName: | VLADIMIR | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301C US ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077738161 | ||||||||
| FaxNumber: | 2077731489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 01/21/2013 | ||||||||
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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 | 363AS0400X | PA-433 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 312580099 | 05 | ME | MEDICAID |