Provider Demographics
NPI:1649249079
Name:CHALOULT, GARY M (NP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:CHALOULT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 S GAGE RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04963-4526
Mailing Address - Country:US
Mailing Address - Phone:207-649-7855
Mailing Address - Fax:207-465-2458
Practice Address - Street 1:35 S GAGE RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963
Practice Address - Country:US
Practice Address - Phone:207-649-7855
Practice Address - Fax:207-465-2458
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81524363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMETPID007828Medicaid
MEP12614Medicare UPIN
ME500025217Medicare PIN