Provider Demographics
NPI:1306373790
Name:PREDICK, MATTHEW BRUCE (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRUCE
Last Name:PREDICK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4135
Mailing Address - Country:US
Mailing Address - Phone:262-325-0810
Mailing Address - Fax:
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:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA173010367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1306373790Medicaid