Provider Demographics
NPI:1316496052
Name:SKVORAK, KASSIE A (PA-C)
Entity type:Individual
Prefix:
First Name:KASSIE
Middle Name:A
Last Name:SKVORAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KASSIE
Other - Middle Name:
Other - Last Name:REUTLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-791-3888
Mailing Address - Fax:
Practice Address - Street 1:11 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04259-7035
Practice Address - Country:US
Practice Address - Phone:207-524-3501
Practice Address - Fax:207-933-9645
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1316496052Medicaid