Provider Demographics
NPI:1194020891
Name:RADWAY, JESSICA ESTHER (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ESTHER
Last Name:RADWAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SEWALL ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2697
Mailing Address - Country:US
Mailing Address - Phone:207-774-5761
Mailing Address - Fax:207-874-7478
Practice Address - Street 1:51 SEWALL ST STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-774-5761
Practice Address - Fax:207-874-7478
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA161551363A00000X
N/A390200000X
MEPA1564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program