Provider Demographics
NPI:1124071287
Name:WAKEMAN, ALFRED S (PA)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:S
Last Name:WAKEMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04643-0082
Mailing Address - Country:US
Mailing Address - Phone:207-483-4502
Mailing Address - Fax:207-483-4778
Practice Address - Street 1:50 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRINGTON
Practice Address - State:ME
Practice Address - Zip Code:04643-3043
Practice Address - Country:US
Practice Address - Phone:207-483-4502
Practice Address - Fax:207-483-4778
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP71073Medicare UPIN
MEWAAP1823Medicare PIN