Basic Information
Provider Information
NPI: 1417963109
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JANKOWSKI
FirstName: ELLEN
MiddleName: B
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 100 GANNETT DR
Address2: SUITE C
City: SOUTH PORTLAND
State: ME
PostalCode: 041065900
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: 08/01/2006
LastUpdateDate: 09/26/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/26/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA10004431WAN Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 
363AM0700XPA10004431WAN Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
363AM0700XPA001161MEN Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
363A00000XPA001161MEY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

ID Information
IDTypeStateIssuerDescription
016656301WAL&I PINOTHER
27217009905ME MEDICAID
832465905WA MEDICAID
54807U01WAREGENCE BLUE SHIELD PINOTHER


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