Provider Demographics
NPI:1811082316
Name:FOGG, ERICH A (PA-C)
Entity type:Individual
Prefix:MR
First Name:ERICH
Middle Name:A
Last Name:FOGG
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:15 HOSPITAL DRIVE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1011
Mailing Address - Country:US
Mailing Address - Phone:207-351-2478
Mailing Address - Fax:207-351-2153
Practice Address - Street 1:112 SANFORD RD
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090-5533
Practice Address - Country:US
Practice Address - Phone:207-641-8100
Practice Address - Fax:207-641-8102
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-12-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MEPA-763363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES41832Medicare UPIN