Provider Demographics
NPI:1912981960
Name:CHASSE, KEITH GREGORY (PAC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:GREGORY
Last Name:CHASSE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-9977
Mailing Address - Country:US
Mailing Address - Phone:207-834-5912
Mailing Address - Fax:207-834-5914
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-9977
Practice Address - Country:US
Practice Address - Phone:207-834-5912
Practice Address - Fax:207-834-5914
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S16479Medicare UPIN