Basic Information
| Provider Information | |||||||||
| NPI: | 1619598125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROY | ||||||||
| FirstName: | ASHLEE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ROY | ||||||||
| OtherFirstName: | ASHLEE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 105D BACK RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ORLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044724310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033659613 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 543 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044013337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079221300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.