Provider Demographics
NPI:1689610776
Name:VANDIVER, MARIANNE F (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:F
Last Name:VANDIVER
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 1:354 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:STONINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04681-3217
Mailing Address - Country:US
Mailing Address - Phone:207-367-2311
Mailing Address - Fax:207-367-2805
Practice Address - Street 1:354 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:STONINGTON
Practice Address - State:ME
Practice Address - Zip Code:04681-3217
Practice Address - Country:US
Practice Address - Phone:207-367-2311
Practice Address - Fax:207-367-2805
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1689610776Medicaid
MEP28545Medicare UPIN
ME431867799Medicaid
MEAP243201Medicare PIN
MEAP243202Medicare PIN