Provider Demographics
NPI:1336218684
Name:BOGDAN, GERALDINE (CNS, NP)
Entity type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:BOGDAN
Suffix:
Gender:F
Credentials:CNS, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3032
Mailing Address - Country:US
Mailing Address - Phone:207-662-3005
Mailing Address - Fax:207-662-3863
Practice Address - Street 1:932 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3032
Practice Address - Country:US
Practice Address - Phone:207-662-3005
Practice Address - Fax:207-662-3863
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER029424364SP0808X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432078399OtherSTATE PROVIDER NO.
ME002448101Medicare PIN