Provider Demographics
NPI:1396845871
Name:LEE, NICOLE C (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:LEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 STATE ST
Mailing Address - Street 2:PO BOX 404
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6616
Mailing Address - Country:US
Mailing Address - Phone:207-973-6670
Mailing Address - Fax:207-973-5226
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-6670
Practice Address - Fax:207-973-5226
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA768363A00000X
MEPA76363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME261710099Medicaid
P81524Medicare UPIN
AP1895Medicare PIN