Provider Demographics
NPI:1376949420
Name:BERTRAM, ANDREA L A (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L A
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 SANFORD RD
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-5543
Mailing Address - Country:US
Mailing Address - Phone:508-630-6143
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:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28219376363LN0000X
NH084794-23363LN0000X
MERN75659363LN0005X
MECNP191305363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1376949420Medicaid
NH3127635Medicaid