Provider Demographics
NPI:1891964508
Name:MCINNIS, CATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:
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:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1358363A00000X
MELC16301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical