Provider Demographics
NPI:1447201165
Name:KAVANAUGH, DOUGLAS LEE (PA-C)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412
Mailing Address - Country:US
Mailing Address - Phone:207-973-5035
Mailing Address - Fax:
Practice Address - Street 1:1 NORTHEAST DR
Practice Address - Street 2:EMMC - NORTHEAST CARDIOLOGY ASSOCIATES
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-275-3800
Practice Address - Fax:207-275-3803
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA561363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAP1112Medicare ID - Type Unspecified