Provider Demographics
NPI:1841225109
Name:GAMACHE, MARY E (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GAMACHE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST UNIT 6B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 CAMPUS DR STE 125
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-883-0069
Practice Address - Fax:207-883-0999
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA166814363L00000X
MECNP181069363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024634BMedicaid
MAS51872Medicare UPIN
MARN0249Medicare PIN