Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DEN4562 | ME |
Y | 213EG0000X | General Practice | DEN4562 | ME |
NPI | 1003336702 |
---|---|
Provider Name | Jacob Fillebrown |
First Address | South Portland, ME 04106-3361 |
Second Address | South Portland, ME 04106-3361 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2017 |
Last Update Date | 23/06/2017 |