Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0102X | Surgical Critical Care | A156409 | CA |
Y | 2086S0102X | Surgical Critical Care | MD23505 | ME |
NPI | 1093077703 |
---|---|
Provider Name | Dr. Stacey Anne Rotta |
First Address | Portland, ME 04102-3100 |
Second Address | Portland, ME 04102-3100 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2012 |
Last Update Date | 23/03/2020 |