Provider Demographics
NPI:1275502056
Name:LANOUETTE, JASON G (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:LANOUETTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CARNOUSTIE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105
Mailing Address - Country:US
Mailing Address - Phone:207-878-8925
Mailing Address - Fax:207-797-8165
Practice Address - Street 1:94 AUBURN STREET
Practice Address - Street 2:#103
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-797-7578
Practice Address - Fax:207-797-8165
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
036569OtherANTHEM
ME206528Medicare ID - Type Unspecified