Provider Demographics
NPI:1265422943
Name:CHADWICK, KRISTINA (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:CHADWICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:ROLLENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7027
Mailing Address - Country:US
Mailing Address - Phone:207-795-0111
Mailing Address - Fax:207-795-7133
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-0111
Practice Address - Fax:207-795-7133
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
010416156OtherCIGNA / GREAT WEST
201017OtherMEDICARE ASC FACILITY
ME261500099Medicaid
MM0716OtherMEDICARE CLINIC FACILITY
010416156OtherCORE / MEDNET / TRAVELERS
0378600001OtherDMERC
AP1070OtherPTAN
025716OtherANTHEM
100294000OtherUSPS WC
970026374OtherRR MEDICARE
1044480OtherAETNA
ME261500099Medicaid