Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | EC151079 | ME |
NPI | 1003297565 |
---|---|
Provider Name | Brock Tostenson |
First Address | Lewiston, ME 04240-7649 |
Second Address | Lewiston, ME 04240-7649 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2015 |
Last Update Date | 10/06/2015 |