Provider Demographics
NPI:1134287188
Name:RADZIUCZ, CARYN P (ANP)
Entity Type:Individual
Prefix:MS
First Name:CARYN
Middle Name:P
Last Name:RADZIUCZ
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MS
Other - First Name:CARYN
Other - Middle Name:
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-4243
Mailing Address - Fax:207-662-6109
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-4243
Practice Address - Fax:207-662-6109
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81026363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENP2670Medicare PIN
MENP267001Medicare PIN
P13531Medicare UPIN