Provider Demographics
NPI:1851309223
Name:ROSEBERRY, KATHRYN W (PA)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:W
Last Name:ROSEBERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:489 STATE ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6616
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:EMERGENCY DEPARTMENT
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:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEPA-286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MER88620Medicare UPIN
MEAP0655Medicare ID - Type Unspecified