Basic Information
| Provider Information | |||||||||
| NPI: | 1457639247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'TOOLE-ROY | ||||||||
| FirstName: | TEAGAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | O'TOOLE | ||||||||
| OtherFirstName: | TEAGAN | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1896 WAGNER BRG | ||||||||
| Address2: | |||||||||
| City: | WALDOBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045725607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079496992 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 35 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074308918 | ||||||||
| FaxNumber: | 2074304320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2011 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1294 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.