Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT533 | ME |
Y | 213ES0000X | Sports Medicine | AT533 | ME |
NPI | 1316508203 |
---|---|
Provider Name | Mason Roy |
First Address | Bangor, ME 04401-2999 |
Second Address | Bangor, ME 04401-2999 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2019 |
Last Update Date | 22/06/2019 |