Provider Demographics
NPI:1437552916
Name:WHITESIDE, HEUSTIS III
Entity Type:Individual
Prefix:
First Name:HEUSTIS
Middle Name:
Last Name:WHITESIDE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-0350
Mailing Address - Country:US
Mailing Address - Phone:207-860-4090
Mailing Address - Fax:207-860-4098
Practice Address - Street 1:107 BOX SHOP HL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-5749
Practice Address - Country:US
Practice Address - Phone:207-860-4090
Practice Address - Fax:207-860-4098
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP141059363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health