Provider Demographics
NPI:1184646762
Name:BASSETT WILLARD, LYNETTE (DO)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:BASSETT WILLARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 TODD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6253
Mailing Address - Country:US
Mailing Address - Phone:207-869-9119
Mailing Address - Fax:207-536-2112
Practice Address - Street 1:43 TODD BROOK RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6253
Practice Address - Country:US
Practice Address - Phone:207-869-9119
Practice Address - Fax:207-869-9117
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1854204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432047699Medicaid
MEMM2204Medicare PIN
MEI65431Medicare UPIN