Provider Demographics
NPI:1336308188
Name:WYATT, MAXEEN (MT)
Entity Type:Individual
Prefix:
First Name:MAXEEN
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1720
Mailing Address - Country:US
Mailing Address - Phone:207-239-4240
Mailing Address - Fax:
Practice Address - Street 1:380 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1720
Practice Address - Country:US
Practice Address - Phone:207-282-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT3231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200890OtherANTHEM BLUE CROSS BLUE SHIELD