Provider Demographics
NPI:1588606065
Name:MASSIE, MARIBETH (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:
Last Name:MASSIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 900
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2443
Practice Address - Country:US
Practice Address - Phone:207-347-2898
Practice Address - Fax:207-553-1415
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR117226367500000X
MERNA113019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD157704200Medicaid
MD157704200Medicaid
MDS70794Medicare UPIN