Provider Demographics
NPI:1376535534
Name:HAN, LAURIE L (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:HAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 MILLS RD
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04046-5705
Mailing Address - Country:US
Mailing Address - Phone:508-897-9440
Mailing Address - Fax:
Practice Address - Street 1:9 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9449
Practice Address - Country:US
Practice Address - Phone:207-284-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246063207R00000X
IN01056644A207R00000X
MEMD25268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200447370OtherIND
INP00042891OtherMEDICARE RAILROAD NUMBER
IN200311740FMedicaid
IN000000263278OtherANTHEM PIN#
IN200447370Medicaid
MA110088045Medicaid
IN7862448OtherAETNA PIN#
INP00042891OtherMEDICARE RAILROAD NUMBER
IN200447370Medicaid
MA110088045Medicaid