Provider Demographics
NPI:1710924600
Name:VAILLANCOURT, JANE KRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:KRISTINE
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:KRISTINE
Other - Last Name:FOLGERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:46 MOOSE TRAIL
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020
Mailing Address - Country:US
Mailing Address - Phone:207-653-9895
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:MAINE MEDICAL CENTER
Practice Address - Street 2:22 BRAMHALL ST.
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-885-0011
Practice Address - Fax:207-885-4467
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME326420099Medicaid
ME326420099Medicaid
MEP00756487Medicare PIN
MEAP140102Medicare PIN
MEAP140101Medicare PIN
MEP24149Medicare UPIN
MEAP1401Medicare PIN
MEAP140103Medicare PIN