Provider Demographics
NPI:1720786916
Name:PLUMMER, RYAN ALAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ALAN
Last Name:PLUMMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CLEAR WATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:ME
Mailing Address - Zip Code:04071-1663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2496363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical