Provider Demographics
NPI:1770578171
Name:LAWHEAD, BRIAN A (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:LAWHEAD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:335 BRIGHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2362
Practice Address - Country:US
Practice Address - Phone:207-662-8600
Practice Address - Fax:207-662-8668
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA506363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP00933903Medicare PIN
ME001877802Medicare PIN
ME001877801Medicare PIN
MES24071Medicare UPIN