Healthcare Provider Details

I. General information

NPI: 1316902489
Provider Name (Legal Business Name): SEAN KEVIN PIECHOCKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 401-741-1884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAT00163
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00486
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number013021
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3777
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: