Provider Demographics
NPI:1720195134
Name:GROFT, ANDREA K (PAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:GROFT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:EMMC, EMERG. MEDICINE
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0404
Mailing Address - Country:US
Mailing Address - Phone:207-973-7250
Mailing Address - Fax:207-973-5656
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:EMMC, EMERG. MEDICINE
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7250
Practice Address - Fax:207-973-5656
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1029057OtherNCCPA CERTIFICATE NUMBER