Provider Demographics
NPI:1881657096
Name:LANDRY, ANTONIO B (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:B
Last Name:LANDRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MOLLISON WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5805
Mailing Address - Country:US
Mailing Address - Phone:207-784-5782
Mailing Address - Fax:207-783-9268
Practice Address - Street 1:33 MOLLISON WAY
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5805
Practice Address - Country:US
Practice Address - Phone:207-784-5782
Practice Address - Fax:207-786-5756
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME267680099Medicaid