Provider Demographics
NPI:1558529776
Name:ROBERTS, JESSE Q (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:Q
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:49 SPRING ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-828-2100
Practice Address - Fax:207-828-2190
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30338125Medicaid
NH30338125Medicaid
ME000605602Medicare PIN