Provider Demographics
NPI:1417055328
Name:DAVIAULT, MAX D (CRNA)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:D
Last Name:DAVIAULT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 HUSSON AVE APT G
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3271
Mailing Address - Country:US
Mailing Address - Phone:207-944-9543
Mailing Address - Fax:
Practice Address - Street 1:307 HUSSON AVE APT G
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3271
Practice Address - Country:US
Practice Address - Phone:207-944-9543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME049419367500000X
MERNA83307367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200051OtherMED B - BHMH
MEME181201OtherMED B - PERS FOR 200051
ME200051OtherMED B - BHMH
MEME181203Medicare PIN
MEME181201OtherMED B - PERS FOR 200051