Provider Demographics
NPI:1538470364
Name:TEVANIAN, ANITA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:
Last Name:TEVANIAN
Suffix:
Gender:F
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 1:190 RIVERSIDE ST
Mailing Address - Street 2:UNIT 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:583 LISBON ST
Practice Address - Street 2:
Practice Address - City:LISBON FALLS
Practice Address - State:ME
Practice Address - Zip Code:04252-1250
Practice Address - Country:US
Practice Address - Phone:207-753-4960
Practice Address - Fax:207-753-4966
Is Sole Proprietor?:No
Enumeration Date:2010-06-26
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME001229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001780301Medicare PIN