Individual
JESUS M GANDARILLAS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
360 BROADWAY, BANGOR, ME 04401-3979
(207) 907-3000
Mailing address
C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT, PO BOX 7291, LEWISTON, ME 04243-7291
(207) 777-8560
(207) 777-8800
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA1819
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1326395971
—
NC
Enumeration date
08/13/2012
Last updated
04/18/2022
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