Provider Demographics
NPI:1386833317
Name:PURI, MINDY L (PA-C)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:L
Last Name:PURI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:L
Other - Last Name:POMERLEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:324 GANNETT DRIVE SUITE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:207-956-6676
Practice Address - Street 1:690 MINOT AVENUE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210
Practice Address - Country:US
Practice Address - Phone:207-783-1328
Practice Address - Fax:207-795-0260
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104404363AS0400X
MEPA001264363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1386833317Medicaid
ME1386833317Medicaid
FLAG620ZMedicare UPIN
FLAG620ZMedicare UPIN