Provider Demographics
NPI:1376548446
Name:KOENIG, PAMELA J (MSN, CRNP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:J
Last Name:KOENIG
Suffix:
Gender:F
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BOYNTON ST
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04631-1306
Mailing Address - Country:US
Mailing Address - Phone:207-853-6001
Mailing Address - Fax:207-853-6180
Practice Address - Street 1:30 BOYNTON ST
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:ME
Practice Address - Zip Code:04631-1306
Practice Address - Country:US
Practice Address - Phone:207-853-6001
Practice Address - Fax:207-853-6180
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008472363LF0000X
MECNP111017363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013058240001Medicaid
PA1013058240001Medicaid
PAQ73221Medicare UPIN