Provider Demographics
NPI:1477817682
Name:NYA, PATRICE AIME
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:AIME
Last Name:NYA
Suffix:
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 1:201 HUSSON AVE APT U12
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3168
Mailing Address - Country:US
Mailing Address - Phone:240-646-4263
Mailing Address - Fax:
Practice Address - Street 1:201 HUSSON AVE APT U12
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3168
Practice Address - Country:US
Practice Address - Phone:240-646-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPI12641390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program