Provider Demographics
NPI:1760729057
Name:BACON, ERIN L (AGACNP)
Entity Type:Individual
Prefix:MISS
First Name:ERIN
Middle Name:L
Last Name:BACON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:MISS
Other - First Name:N/A
Other - Middle Name:NA
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGACNP
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP151103363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400255689Medicare PIN
MEE400255684Medicare PIN