Basic Information
| Provider Information | |||||||||
| NPI: | 1588012314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARADIS | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALBERT | ||||||||
| OtherFirstName: | KENDRA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT | ||||||||
| Address2: | PO BOX 7291 | ||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042437291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778941 | ||||||||
| FaxNumber: | 2077774397 | ||||||||
| Practice Location | |||||||||
| Address1: | 329 WILSON ST | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073073000 | ||||||||
| FaxNumber: | 2079071043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2016 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO2873 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1588012314 | 05 | ME | MEDICAID |