Provider Demographics
NPI:1417026634
Name:WORMWOOD, VLADIMIR J (PA-C)
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:J
Last Name:WORMWOOD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:818 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3112
Practice Address - Country:US
Practice Address - Phone:207-773-8161
Practice Address - Fax:207-773-1489
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-433363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME312580099Medicaid
MEAP0398Medicare PIN
MEAP039801Medicare PIN
MES45059Medicare UPIN
ME312580099Medicaid