Provider Demographics
NPI:1508968298
Name:GATCOMB, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:GATCOMB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 METCALF RD
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-3371
Mailing Address - Country:US
Mailing Address - Phone:207-623-8411
Mailing Address - Fax:207-621-7315
Practice Address - Street 1:1 VA CTR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6719
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:207-621-7315
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI662133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered