Provider Demographics
NPI:1336607928
Name:THIBODEAU, PATRICIA A (BSPT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-2125
Mailing Address - Country:US
Mailing Address - Phone:207-723-7229
Mailing Address - Fax:
Practice Address - Street 1:899 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-2125
Practice Address - Country:US
Practice Address - Phone:207-723-7229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT866208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME01-0223482OtherMILLINOCKET REGIONAL HOSPITAL