Basic Information
| Provider Information | |||||||||
| NPI: | 1932628450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COYNE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | O'NEIL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 92 CAMPUS DR STE C | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077975753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 92 CAMPUS DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077975753 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2017 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | MA059270 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA2311 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA2311 | 01 | ME | MAINE STATE CERTIFICATION | OTHER |