Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 1804 | ME |
NPI | 1679668453 |
---|---|
Provider Name | Leslie Robin Gass |
First Address | Portland, ME 04103-4973 |
Second Address | Portland, ME 04103-4973 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 24/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1116014 | AETNA (01) | |
I46993 | (02) |