Provider Demographics
NPI:1770512956
Name:RACZKOWSKI, RUTH A (NP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:A
Last Name:RACZKOWSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67 EUSTIS PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5173
Mailing Address - Country:US
Mailing Address - Phone:207-873-2136
Mailing Address - Fax:207-660-4529
Practice Address - Street 1:1135 MORTON ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2834
Practice Address - Country:US
Practice Address - Phone:617-533-2400
Practice Address - Fax:617-533-2401
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP161020363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARANP3730Medicare ID - Type Unspecified
MAP53427Medicare UPIN