Healthcare Provider Details

I. General information

NPI: 1285189845
Provider Name (Legal Business Name): DAVID DECOTEAU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

399 REVOLUTION DR STE 458
SOMERVILLE MA
02145-1488
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4100
  • Fax:
Mailing address:
  • Phone: 860-972-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5893
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.003656
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003656
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: