Basic Information
| Provider Information | |||||||||
| NPI: | 1841225109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAMACHE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE ST UNIT 6B | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031073 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 CAMPUS DR STE 125 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078830069 | ||||||||
| FaxNumber: | 2078830999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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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 | 363L00000X | 166814 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | CNP181069 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 110024634B | 05 | MA | MEDICAID |