Basic Information
| Provider Information | |||||||||
| NPI: | 1538470364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEVANIAN | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE ST | ||||||||
| Address2: | UNIT 6B | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077774111 | ||||||||
| FaxNumber: | 2077836660 | ||||||||
| Practice Location | |||||||||
| Address1: | 583 LISBON ST | ||||||||
| Address2: | |||||||||
| City: | LISBON FALLS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042521250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077534960 | ||||||||
| FaxNumber: | 2077534966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2010 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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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 | 363A00000X | 001229 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.